Kellie Stockton

Fatigue, muscle strength and vitamin D status in women with systemic lupus erythematosus compared with healthy controls

Recent studies have demonstrated an inverse relationship between vitamin D levels and fatigue in systemic lupus erythematosus (SLE). The aims of this study were to evaluate proximal muscle strength, fatigue and vitamin D levels in women with SLE compared with healthy controls and to investigate relationships between these factors in a cohort of women with SLE. Forty-five women (24 SLE, 21 healthy controls) participated. Primary outcome measures were the fatigue severity scale (FSS), isometric muscle strength of dominant limbs using hand held dynamometry, two functional tests – the 30-second chair stand test and the 1-kg arm lift test, with vitamin D status measured using 25(OH)D. Overall 25(OH)D levels were 68.4 (22.4) nmol/L with no difference between SLE and control groups. There was a statistically and clinically significant difference in fatigue, 1-kg arm lift, 30-second sit to stand, knee extension, hip flexion, hip abduction, shoulder flexion and grip strength in the SLE group compared with the control group (p < 0.05). In the SLE group FSS was moderately correlated with both functional measures (1-kg arm lift r = −0.42, 30-second chair stand r = −0.44, p < 0.05). However, no statistically significant correlation between dynamometry measures and fatigue was evident. There was no association between fatigue and 25(OH)D level (r = −0.12). In summary, women with SLE were weaker and demonstrated reduced physical function and higher fatigue levels than healthy controls. Fatigue was related to physical function but not vitamin D status or maximal isometric strength in vitamin D replete individuals with SLE.

Effect of multiple physiotherapy sessions on functional outcomes in the initial postoperative period after primary total hip replacement: a randomized controlled trial.

UNLABELLED Stockton KA, Mengersen KA. Effect of multiple physiotherapy sessions on functional outcomes in the initial postoperative period after primary total hip replacement: a randomized controlled trial. OBJECTIVE To determine whether increasing physiotherapy input from once to twice per day will result in earlier achievement of functional milestones (ie, independence in mobility and transfers) and decreased length of stay (LOS) in patients undergoing a primary total hip replacement. DESIGN Randomized controlled trial. SETTING Metropolitan private hospital. PARTICIPANTS Patients (N=57) with primary total hip replacement were randomly assigned to the twice daily (treatment, n=30) and once daily (control, n=27) groups. Patients who chose to attend hydrotherapy were excluded from the randomization process; however, they gave consent for outcome measures to be collected for comparison with the randomized groups. INTERVENTIONS The control group received usual care, and the treatment group received twice-daily physiotherapy from day 1 after surgery to discharge. MAIN OUTCOME MEASURES The Iowa Level of Assistance at postoperative days 3 and 6 and LOS. RESULTS This study demonstrates that patients who received twice-daily land-based physiotherapy after primary total hip replacement attained earlier achievement of functional milestones than patients that received once-daily physiotherapy. A statistically significant (P=.041) but not clinically significant difference was evident in the Iowa Level of Assistance score at day 3. There was no difference between the groups in Iowa Level of Assistance measures on day 6 or on LOS. CONCLUSIONS Patients who received twice-daily physiotherapy showed a trend toward earlier achievement of functional milestones; however, this finding did not translate to decreased LOS.

Intensive exercise after thermal injury improves physical, functional, and psychological outcomes.

BACKGROUND Although exercise programs after burns are considered a standard of care, there is limited evidence for efficacy in adult patients. This study aimed to investigate the effects of an exercise program on physical, functional, and quality of life measures. METHODS A quasi-experimental controlled trial was instituted after final grafting. Both groups completed stretching, and the intervention group underwent a supervised high-intensity (80% maximal heart rate and 70% three repetition maximum) combined aerobic or resisted exercise program for 6 weeks, with outcome measures at baseline, 6 weeks, and 3 months by a blinded assessor. Analysis was by intention to treat. RESULTS Thirty patients (24 men) with a mean age of 34.3 years (± 13.1 years) and mean total body surface area 42.9% (± 13.3%) were enrolled. Inequalities at baseline (age and total body surface area %) were adjusted statistically. A between within repeated measures analysis of variance found significant group × time effects between the groups. Mean change scores from baseline to 12 weeks between control and intervention groups, respectively, were strength (kg): quadriceps (17.5 vs. 66.87), latissimus dorsi (6.07 vs. 27.82), right (4.86 vs. 14.86) and left (7.26 vs. 16.83) hand grip; fitness: peak oxygen consumption (L/min; 0.11 vs. 0.93) and shuttle walk distance (m; 168.93 vs. 459); function: lower extremity function score (8.87 vs. 27.31) and QuickDash (−5.7 vs. −23.98); and health-related quality of life: Burns-Specific Health Scale—Abbreviated (−7.64 vs. 35.13). There were no adverse events during either testing or training. CONCLUSION A high-intensity cardiovascular or resisted exercise program resulted in significant improvements in functional, physical, and psychologic measures and should be mandatory for all burns patients. Larger multicenter trials with longer follow-up periods are required. LEVEL OF EVIDENCE Therapeutic study, level III.

Randomized controlled trial of three burns dressings for partial thickness burns in children

BACKGROUND This study compared the effects of three silver dressing combinations on small to medium size acute partial thickness burns in children, focusing on re-epithelialization time, pain and distress during dressing changes. METHOD Children (0-15 years) with clean, ≤ 10% total body surface area (TBSA) partial thickness burns who met the inclusion criteria were included in the study. Children received either (1) Acticoat™; (2) Acticoat™ with Mepitel™; or (3) Mepilex Ag™ dressings. Measures of burn re-epithelialization, pain, and distress were recorded at dressing changes every 3-5 days until full re-epithelialization occurred. RESULTS One hundred and three children were recruited with 96 children included for analysis. No infections were detected for the course of the study. When adjusted for burn depth, Acticoat™ significantly increased the expected days to full re-epithelialization by 40% (IRR = 1.40; 95% CI: 1.14-1.73, p < 0.01) and Acticoat™ with Mepitel™ significantly increased the expected days to full re-epithelialization by 33% (IRR = 1.33; 95% CI: 1.08-1.63, p ≤ 0.01) when compared to Mepilex Ag™. Expected FLACC scores in the Mepilex Ag™ group were 32% lower at dressing removal (p = 0.01) and 37% lower at new dressing application (p = 0.04); and scores in the Acticoat™ with Mepitel™ group were 23% lower at dressing removal (p = 0.04) and 40% lower at new dressing application (p < 0.01), in comparison to the Acticoat™ group. Expected Visual Analog Scale-Pain (VAS-P) scores were 25% lower in the Mepilex Ag™ group at dressing removal (p = 0.04) and 34% lower in the Acticoat™ with Mepitel™ group (p = 0.02) at new dressing application in comparison to the Acticoat™ group. There was no significant difference between the Mepilex Ag™ and the Acticoat™ with Mepitel™ groups at all timepoints and with any pain measure. CONCLUSION Mepilex Ag™ is an effective silver dressing, in terms of accelerated wound re-epithelialization time (compared to Acticoat™ and Acticoat™ with Mepitel™) and decreased pain during dressing changes (compared to Acticoat™), for clean, < 10% TBSA partial thickness burns in children.

3D photography is as accurate as digital planimetry tracing in determining burn wound area

BACKGROUND In the paediatric population careful attention needs to be made concerning techniques utilised for wound assessment to minimise discomfort and stress to the child. AIM To investigate whether 3D photography is a valid measure of burn wound area in children compared to the current clinical gold standard method of digital planimetry using Visitrak™. METHOD Twenty-five children presenting to the Stuart Pegg Paediatric Burn Centre for burn dressing change following acute burn injury were included in the study. Burn wound area measurement was undertaken using both digital planimetry (Visitrak™ system) and 3D camera analysis. Inter-rater reliability of the 3D camera software was determined by three investigators independently assessing the burn wound area. RESULTS A comparison of wound area was assessed using intraclass correlation co-efficients (ICC) which demonstrated excellent agreement 0.994 (CI 0.986, 0.997). Inter-rater reliability measured using ICC 0.989 (95% CI 0.979, 0.995) demonstrated excellent inter-rater reliability. Time taken to map the wound was significantly quicker using the camera at bedside compared to Visitrak™ 14.68 (7.00)s versus 36.84 (23.51)s (p<0.001). In contrast, analysing wound area was significantly quicker using the Visitrak™ tablet compared to Dermapix(®) software for the 3D Images 31.36 (19.67)s versus 179.48 (56.86)s (p<0.001). CONCLUSION This study demonstrates that images taken with the 3D LifeViz™ camera and assessed with Dermapix(®) software is a reliable method for wound area assessment in the acute paediatric burn setting.

A prospective observational study investigating all children presenting to a specialty paediatric burns centre

AIM AND METHOD The aim of this study was to describe the mechanism of injury and outcome of all children who presented to The Stuart Pegg Paediatric Burns Centre (SPPBC) with a burn injury in the year 2013. A detailed proforma was completed prospectively at time of presentation to hospital. RESULTS During the one year period, 758 children with a median age of 2 years 3 months presented with a burn injury. Overall, 12.7% of patients (n=96) were initially treated as inpatients. Similarities existed between in and outpatients. Over half the children admitted had a scald injury (53.1%). Whilst slightly higher than the outpatient scald rate of 43.1% there was no statistical significant difference. However, there was a significant difference between inpatients and outpatients with respect to other mechanisms of injury. Contact burns were under represented in inpatients (27.1%) compared to outpatients (44.5%), p<0.05. In contrast, flame burns were over represented in inpatients, 11.5% compared to outpatients, 2.9% (p<0.05). CONCLUSION Paediatric burns are a common cause of childhood injury. The majority of children present with small to medium sized partial thickness injuries and are managed as outpatients. In order to understand the true impact of paediatric burn injury and to develop appropriate targeted injury prevention campaigns, data repositories must include detailed information regarding outpatient paediatric burns.

Burn resuscitation--hourly urine output versus alternative endpoints: a systematic review.

ABSTRACT Controversy remains over appropriate endpoints of resuscitation during fluid resuscitation in early burns management. We reviewed the evidence as to whether utilizing alternative endpoints to hourly urine output produces improved outcomes. MEDLINE, CINAHL, EMBASE, Cochrane Library, Web of Science, and full-text clinicians’ health journals at OVID, from 1990 to January 2014, were searched with no language restrictions. The keywords burns AND fluid resuscitation AND monitoring and related synonyms were used. Outcomes of interest included all-cause mortality, organ dysfunction, length of stay (hospital, intensive care), time on mechanical ventilation, and complications such as incidence of pulmonary edema, compartment syndromes, and infection. From 482 screened, eight empirical articles, 11 descriptive studies, and one systematic review met the criteria. Utilization of hemodynamic monitoring compared with hourly urine output as an endpoint to guide resuscitation found an increased survival (risk ratio [RR], 0.58; 95% confidence interval, 0.42–0.85; P < 0.004), with no effect on renal failure (RR, 0.77; 95% confidence interval, 0.39–1.43; P = 0.38). However, inclusion of the randomized controlled trials only found no survival advantage of hemodynamic monitoring over hourly urine output (RR, 0.72; 95% confidence interval, 0.43–1.19; P = 0.19) for mortality. There were conflicting findings between studies for the volume of resuscitation fluid, incidence of sepsis, and length of stay. There is limited evidence of increased benefit with utilization of hemodynamic monitoring, however, all studies lacked assessor blinding. A large multicenter study with a priori–determined subgroup analysis investigating alternative endpoints of resuscitation is warranted.

The efficacy and safety of adrenergic blockade after burn injury: A systematic review and meta-analysis.

BACKGROUND The hypermetabolic state after severe burns is a major problem that can lead to several pathophysiologic changes and produce multiple sequelae. Adrenergic blockade has been widely used to reverse these changes and improve outcomes in burned patients but has not been rigorously evaluated. The aim of this systematic review was to investigate the efficacy and safety of the use of adrenergic blockade after burn injury. METHODS The databases MEDLINE via OVID, PubMed, EMBASE, CINAHL, Cochrane Library, and Web of Science were searched from inception to December 2014 with search terms including burns and beta-blockers with appropriate synonyms. Articles were restricted to those published in English, French, or Spanish. Randomized controlled trials, nonrandomized controlled trials, and systematic reviews were screened. After an independent screening and full-text review, 10 articles were selected, and an appraisal of risk of bias was performed. RESULTS From 182 articles screened, 9 randomized controlled trials and 1 nonrandomized controlled trial met the inclusion criteria. Pooled analyses were performed to calculate effect sizes and 95% confidence intervals (CIs). There was a positive effect favoring propranolol use that significantly decreased resting energy expenditure (g = −0.64; 95% CI, −0.8 to −0.5; p < 0.001) and trunk fat (g = −0.3; 95% CI, −0.4 to −0.1; p < 0.001) as well as improved peripheral lean mass (g = 0.45; 95% CI, 0.3–0.6; p < 0.001) and insulin resistance (g = −1.35; 95% CI, −2.0 to −0.6; p < 0.001). Occurrence of adverse events was not significantly different between the treated patients the and controls. CONCLUSION Limited evidence suggests beneficial effects of propranolol after burn injury, and its use seems safe. However, further trials on adult population with a broader range of outcome measures are warranted. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.

Test–retest reliability of hand-held dynamometry and functional tests in systemic lupus erythematosus

The aim of this study was to evaluate the test–retest reliability and determine the degree of measurement error of tests of isometric muscle strength and upper and lower limb function in women with systemic lupus erythematosus (SLE). Twelve women with SLE (age 39.8 ± 10 years) were assessed on two occasions separated by a 7–10-day interval. Strength of six muscle groups was measured using a hand-held dynamometer; function was measured by the 30-s sit to stand test and the 30-s 1 kg arm lift. Relative reliability was estimated using the intraclass correlation coefficient (ICC), model 2,1 (ICC2,1). Absolute reliability was estimated using standard error measurement and the minimal detectable difference was calculated. All ICCs were greater than 0.87. Muscle strength would need to increase by between 18% and 39% in women with SLE to be 95% confident of detecting real changes. The functional tests demonstrated a systematic bias between trials. This study demonstrates that hand-held dynamometry in SLE can be performed with excellent reliability. Further work needs to be completed to determine the number of trials necessary for both the 30-s sit to stand and 30-s 1 kg arm lift to decrease the systematic bias.

Physiological Responses to Maximal Exercise Testing and the Modified Incremental Shuttle Walk Test in Adults After Thermal Injury: A Pilot Study

The ongoing hypermetabolic response associated with burn injury contributes significantly to loss of function, morbidity, and mortality. Exercise is strongly recommended to assist recovery and overall functional outcome. To date, there have been limited studies investigating the validity and practicality of both maximal laboratory and field tests in adult burns survivors. The objective of this study was to determine the metabolic and ventilatory response to cardiopulmonary maximal exercise testing (CPET) and the modified shuttle walk test (MSWT) in adult burns patients. Fifteen people (13 male) with a mean TBSA of 38.5% (16.0%) underwent both MSWT and CPET within a 5-day period in random order. The majority of participants demonstrated a normal response to CPET. Two participants with a history of inhalation burns demonstrated a respiratory limitation to exercise with desaturation (91 and 89%) at the end of the CPET, which returned to normal within 2 minutes after exercise. The correlation between VO2peak as measured via CPET and distance as measured in MSWT was 0.7. Mean results measured in MSWT for maximal heart rate and perceived exertion scores were lower than those achieved with CPET results: 91 and 88%, respectively. There were no adverse events during both the MSWT and CPET. This study demonstrates that after burn injury, CPET and MSWT can be performed safely in the majority of patients early in the postdischarge rehabilitation period. MSWT is likely to be submaximal at 80 to 90% of CPET results but is easy to replicate and cost-effective, thus a viable mechanism for monitoring aerobic capacity.