Jonathan B. Imran

Nutrition and metabolism in burn patients

Severe burn causes significant metabolic derangements that make nutritional support uniquely important and challenging for burned patients. Burn injury causes a persistent and prolonged hypermetabolic state and increased catabolism that results in increased muscle wasting and cachexia. Metabolic rates of burn patients can surpass twice normal, and failure to fulfill these energy requirements causes impaired wound healing, organ dysfunction, and susceptibility to infection. Adequate assessment and provision of nutritional needs is imperative to care for these patients. There is no consensus regarding the optimal timing, route, amount, and composition of nutritional support for burn patients, but most clinicians advocate for early enteral nutrition with high-carbohydrate formulas.Nutritional support must be individualized, monitored, and adjusted throughout recovery. Further investigation is needed regarding optimal nutritional support and accurate nutritional endpoints and goals.

Acute kidney injury after burn

Acute kidney injury (AKI) is a common and morbid complication after severe burn, with an incidence and mortality as high as 30% and 80%, respectively. AKI is a broad clinical condition with many etiologies, which makes definition and diagnosis challenging. The most recent Kidney Disease: Improving Global Outcomes (KDIGO) consensus guidelines defined stage and severity of AKI based on changes of serum creatinine and urine output (UOP) across time. Burn-related kidney injury is typically classified as early (0-3days after injury) or late (4-14days after injury). Early burn AKI is typically due to hypovolemia, poor renal perfusion, direct cardiac suppression from TNF-alpha, and precipitation of denatured proteins, while late AKI is often due to sepsis, multi-organ failure, and nephrotoxic drugs. Diagnosis can be difficult as UOP and biochemical markers can be relatively normal even with significant renal injury. A sensitive and specific biomarker for the early diagnosis of AKI is sorely needed, and multiple potential biomarkers are being investigated. For treatment, the reversal of the underlying cause is the first intervention. The advent of renal replacement therapy has significantly improved the mortality of burn patients with AKI and should be initiated early if injury progresses despite initial maneuvers. Unfortunately, no beneficial pharmacologic agents have been identified, despite multiple investigations. Of burn patients who survive AKI, the vast majority do not receive long-term hemodialysis and they are generally thought to have a good renal prognosis although this view is shifting. Preliminary data in the burn population suggest that AKI may confer an increased risk of end-stage renal disease and long-term all-cause mortality, but further research is needed.

Can We Reliably Predict a Clinical Complete Response in Rectal Cancer? Current Trends and Future Strategies

Purpose of ReviewPrediction of clinical complete response is pivotal in the management of patients with rectal cancer. The ability to determine tumor response to neoadjuvant therapy in rectal cancer might guide subsequent treatment modalities. We review the current literature on predictors of complete response after neoadjuvant for rectal cancer with an emphasis of clinical complete response rather than pathological complete response.Recent FindingsClinical and radiological findings have been used to predict response, as well as a myriad of biomarkers. There is limited evidence validating most of these strategies. The role of imaging in defining tumor response has been assessed retrospectively. The TRIGGER trial is a randomized trial that will evaluate stratified management of rectal cancer based on their tumor regression grade.SummaryThe management of locally advanced rectal cancer is evolving. The ability to predict clinical complete response in patients that have undergone neoadjuvant chemoradiation will allow us to select potential patients that can benefit from a “watch and wait” strategy. Identifying patients that will have a complete response will result in decreased surgical overtreatment, favoring organ-sparing strategies. Treatment individualization will require further research. Emphasis should be made in validating prediction markers; these should be cost-effective and of minimally invasive retrieval. Surveillance protocols to assess for tumor regrowth are yet to be determined.

Predictors of a histopathologic diagnosis of complicated appendicitis

BACKGROUND Despite its utilization, the intraoperative (IO) assessment of complicated appendicitis (CA) is subjective. The histopathologic (HP) diagnosis should be the gold standard in identifying patients with CA; however, it is not immediately available to guide postoperative management. The objective of this study was to identify predictors of an HP diagnosis of CA. MATERIALS AND METHODS A retrospective review of all patients who underwent appendectomy at our institution from 2011-2013 was conducted. CA was defined by perforation or abscess on pathology report. Predictors of an HP diagnosis of CA were evaluated using a multivariable regression model. RESULTS A total of 239 of 1066 patients had CA based on IO assessment, whereas 143 of 239 patients (60%) had CA on HP and IO assessment. On multivariable analysis, an IO diagnosis of CA was associated with an HP diagnosis of CA (odds ratio [OR]: 10.92; 95% confidence interval [CI]: 7.19-16.58). Other risk factors were age (OR: 1.28; 95% CI: 1.09-1.49), number of days of pain (OR: 1.20; 95% CI: 1.07-1.37), increased heart rate (OR: 1.14; 95% CI: 1.02-1.26), appendix size (OR: 1.09; 95% CI: 1.03-1.16), and an appendicolith (OR: 1.74; 95% CI: 1.12-2.71) on preoperative CT imaging. CONCLUSIONS In addition to age, increased heart rate, pain duration, appendix size and appendicolith, the IO assessment is also associated with an HP diagnosis of CA; however, 40% of patients were incorrectly classified. Using these predictors with improved IO grading may achieve more accurate diagnosis of CA.

The Relationship Between Frailty and the Subjective Decision to Conduct a Goals of Care Discussion With Burned Elders

Best practices are to conduct an early discussion of goals of care (GoC) after injury in the elderly, but this intervention is inconsistently applied. We hypothesized that a frail appearance was a factor in the decision to conduct a GoC discussion after thermal injury. A retrospective review was performed of all burn survivors aged ≥ 65 years at our American Burn Association (ABA)-verified level 1 burn center between April 02, 2009, and December 30, 2014. Demographic information included age, gender, mechanism of injury, percentage TBSA burned, revised Baux score, patient/physician racial discordance, documented GoC discussion (as defined within the electronic medical record), length of stay (LOS), and disposition. One rater retrospectively assigned clinical frailty scores to patients using the Canadian Study of Health and Aging Criteria, which ranged from 1 (very fit) to 7 (severely frail). Ordinal logistic regression was performed. Demographics for the cohort of 126 subjects were (mean ± SD): age = 75.5 ± 7.7 years, %TBSA burned = 11.9% ± 7.2, revised Baux = 87.8 ± 10.2, hospital LOS (days) = 14.9 ± 13.7, Intensive Care Unit (ICU) LOS (days) = 6.2 ± 1.2, frailty score = 4.1 ± 1.1. Overall, 72% of geriatric survivors had a favorable discharge disposition. GoC discussions occurred in 25% of patients. GoC discussion (OR, 3.42; 95% CI, 1.54-7.60) and an unfavorable disposition (OR, 9.01; 95% CI, 3.91-20.78) were associated with greater predicted odds of receiving a higher ordered frailty score. Our results suggest that, even in the absence of a formal diagnosis, a frail appearance may influence a providers decision to perform GoC discussions after severe thermal injury.

Burn Surgeon and Palliative Care Physician Attitudes Regarding Goals of Care Delineation for Burned Geriatric Patients

Palliative care specialists (PCS) and burn surgeons (BS) were surveyed regarding: 1) importance of goals of care (GoC) conversations for burned seniors; 2) confidence in their own specialtys ability to conduct these conversations; and 3) confidence in the ability of the other specialty to do so. A 13-item survey was developed by the steering committee of a multicenter consortium dedicated to palliative care in the injured geriatric patient and beta-tested by BS and PCS unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Burn Association and American Academy for Hospice and Palliative Medicine. Forty-five BS (7.3%) and 244 PCS (5.7%) responded. Palliative physicians rated being more familiar with GoC, were more comfortable having a discussion with laypeople, were more likely to have reported high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to BS. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so. BS favored leading team discussions, whereas palliative specialists preferred jointly led discussions. Both groups agreed that discussions should occur within 72 hours of admission. Both groups believe themselves to conduct GoC discussions for burned seniors better than the other specialty perceived them to do so, which led to disparate views on perceptions for the optimal leadership of these discussions.

Impact of a Laser Service Line for Burn Scar on a Dedicated Burn OR’s Flow and Productivity

Our group began performing erbium-YAG 2940 wavelength fractional resurfacing of burn scar in our burn centers dedicated burn operating room (OR) in January 2016. The impact of these procedures on the performance of a mature, dedicated burn OR is unknown. All burn OR cases performed between January 1, 2015 and December 31, 2015 served as a pre-laser (PRE-LSR) historical control. A postintervention cohort of laser-only cases (LSR) performed between January 1, 2016 and August 17, 2016 was then identified. PRE-LSR and LSR cases were retrospectively reviewed for OR component times, and work relative value units (wRVU) billed. A total of 628 burn OR cases were done in 2015 (PRE-LSR), while 488 burn OR cases were done between January 1 and August 17, 2016. Of these 488, 59 cases were LSR (12.1%). Calculated on a monthly basis, significantly more cases were done per day in the LSR era (2.2 ± 0.4 cases/d) than PRE-LSR (1.6 ± 2.0 cases/d; P < .0001). The LSR group was significantly shorter than the PRE-LSR group for all OR component times (induction, prep, and procedure all P < .0001; transport out, P = .01; room turnover, P = .004). Aggregate OR component time was 79.2 ± 33.4 minutes for LSR and 157.5 ± 65.0 minutes for PRE-LSR (P < .0001). LSR yielded 6.9 ± 3.2 wRVU/h, while PRE-LSR generated 12.2 ± 8.9 wRVU/h (P < .0001). Despite significantly shorter OR component times and more cases being done per day, laser treatment of burn scar using a single 17108 Current Procedural Terminology code cuts wRVUs generated per hour in a mature burn OR roughly in half.

Acute Kidney Injury After Burn: A Cohort Study From the Parkland Burn Intensive Care Unit

Acute kidney injury (AKI) is a common and morbid complication in patients with severe burn. The reported incidence of AKI and mortality in this population varies widely due to inconsistent and changing definitions. They aimed to examine the incidence, severity, and hospital mortality of patients with AKI after burn using consensus criteria. This is a retrospective cohort study of adults with thermal injury admitted to the Parkland burn intensive care unit (ICU) from 2008 to 2015. One thousand forty adult patients with burn were admitted to the burn ICU. AKI was defined by KDIGO serum creatinine criteria. Primary outcome includes hospital death and secondary outcome includes length of mechanical ventilation, ICU, and hospital stay. All available serum creatinine measurements were used to determine the occurrence of AKI during the hospitalization. All relevant clinical data were collected. The median total body surface area (TBSA) of burn was 16% (IQR: 6%-29%). AKI occurred in 601 patients (58%; AKI stage 1, 60%; stage 2, 19.8%; stage 3, 10.5%; and stage 3 requiring renal replacement therapy [3-RRT], 9.7%). Patients with AKI had larger TBSA burn (median 20.5% vs 11.0%; P < .001) and more mechanical ventilation and hospitalization days than patients without AKI. The hospital death rate was higher in those with AKI vs those without AKI (19.7% vs 3.9%; P < .001) and increased by each AKI severity stage (P trend < .001). AKI severity was independently associated with hospital mortality in the small burn group (for TBSA ≤ 10%: stage 1 adjusted OR 9.3; 95% CI, 2.6-33.0; stage 2-3 OR, 35.0; 95% CI, 9.0-136.8; stage 3-RRT OR, 30.7; 95% CI, 4.2-226.4) and medium burn group (TBSA 10%-40%: stage 2-3 OR, 6.5; 95% CI, 1.9-22.1; stage 3-RRT OR, 35.1; 95% CI, 8.2-150.3). AKI was not independently associated with hospital death in the large burn group (TBSA > 40%). Urine output data were unavailable. AKI occurs frequently in patients after burn. Presence of and increasing severity of AKI are associated with increased hospital mortality. AKI appears to be independently and strongly associated with mortality in patients with TBSA ≤ 40%. Further investigation to develop risk-stratification tools tailoring this susceptible population is direly needed.

Nitric Oxide in Rectal Cancer: From Mice to Patients

The wide response to treatment in rectal cancer to neoadjuvant chemoradiation (CRT) provides a unique opportunity to study the role of agents to overcome resistance. Up to one-fourth of patients treated with CRT experience no observable response to the same treatment where similarly treated patients might achieve a complete regression of the tumor. We have developed in vitro and in vivo models for the study of radioresistance. We have employed several agents to overcome tumor resistance and found that nitric oxide was one of the most potent radiosensitizers. We extended our experience in vivo and undertook a phase I dose-escalation trial with the goal of determining the safety of utilizing nitric oxide from nitroglycerine transdermal patches in addition to conventional treatment in patients with rectal cancer. The present discussion addresses our models of rectal cancer and the results of our radiosensitizing strategies with nitric oxide from mice to patients.

Can CT imaging of the chest, abdomen, and pelvis identify all vertebral injuries of the thoracolumbar spine without dedicated reformatting?

BACKGROUND The main objective of this study was to compare detection rates of clinically significant thoracolumbar spine (TLS) fracture between computed tomography (CT) imaging of the chest, abdomen, and spine (CT CAP) and CT for the thoracolumbar spine (CT TL). METHODS We retrospectively identified patients at our institution with a TLS fracture over a two-year period that had both CT CAP and reformatted CT TL imaging. The sensitivity of CT CAP to identify fracture was calculated for each fracture type. RESULTS A total of 516 TLS fractures were identified in 125 patients using reformatted CT TL spine imaging. Overall, 69 of 512 fractures (13%) were missed on CT CAP that were identified on CT TL. Of those, there were no clinically significant missed fractures. CONCLUSIONS CT CAP could potentially be used as a screening tool for clinically significant TLS injuries.