Background: Developments in critical care and surgical approaches to treating burn wounds, together with newer antimicrobial treatments, have significantly reduced the morbidity and mortality rates associated with this injury. Methods: Review of the pertinent English-language literature. Results: Several resistant organisms have emerged as the maleficent cause of invasive infection in burn patients, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, Pseudomonas, Acinetobacter, non-albicans Candida spp., and Aspergillus. Advances in antimicrobial therapies and the release of new classes of antibiotics have certainly added to the armamentarium of therapeutic resources for the clinician. Conclusion: Strict infection control measures, constant wound surveillance with regular sampling of tissues for quantitative culture, and early excision and wound closure remain the principal adjuncts to control of invasive infections in burn patients.

Study objective The National Institutes of Health Stroke Scale (NIHSS) measures deficits caused by a stroke, but not all stroke signs are captured on the NIHSS. We determined the symptoms and stroke localization of patients with brain infarction and an NIHSS score of 0. Methods We studied all patients who presented with acute neurological symptoms to our stroke center from 2004–2008, had persistent symptoms at the time of evaluation in the emergency department, an NIHSS score of 0, and an infarct on diffusion weighted imaging (DWI). We characterized the symptoms, signs, lesion location, demographics and stroke etiologies. Results 20 patients met inclusion criteria. Symptoms frequently experienced were headache, vertigo, and nausea. The posterior circulation was commonly infarcted in this group. Truncal ataxia was the most common neurological sign. Conclusion Ischemic stroke may cause symptoms that are associated with no deficits on the NIHSS score.

BackgroundLimited information has been published regarding standard quality assurance (QA) procedures for stroke registries. We share our experience regarding the establishment of enhanced QA procedures for the University of Texas Houston Stroke Registry (UTHSR) and evaluate whether these QA procedures have improved data quality in UTHSR.MethodsAll 5093 patient records that were abstracted and entered in UTHSR, between January 1, 2008 and December 31, 2011, were considered in this study. We conducted reliability and validity studies. For reliability and validity of data captured by abstractors, a random subset of 30 records was used for re-abstraction of select key variables by two abstractors. These 30 records were re-abstracted by a team of experts that included a vascular neurologist clinician as the “gold standard”. We assessed inter-rater reliability (IRR) between the two abstractors as well as validity of each abstractor with the “gold standard”. Depending on the scale of variables, IRR was assessed with Kappa or intra-class correlations (ICC) using a 2-way, random effects ANOVA. For assessment of validity of data in UTHSR we re-abstracted another set of 85 patient records for which all discrepant entries were adjudicated by a vascular neurology fellow clinician and added to the set of our “gold standard”. We assessed level of agreement between the registry data and the “gold standard” as well as sensitivity and specificity. We used logistic regression to compare error rates for different years to assess whether a significant improvement in data quality has been achieved during 2008–2011.ResultsThe error rate dropped significantly, from 4.8% in 2008 to 2.2% in 2011 (P < 0.001). The two abstractors had an excellent IRR (Kappa or ICC ≥ 0.75) on almost all key variables checked. Agreement between data in UTHSR and the “gold standard” was excellent for almost all categorical and continuous variables.ConclusionsEstablishment of a rigorous data quality assurance for our UTHSR has helped to improve the validity of data. We observed an excellent IRR between the two abstractors. We recommend training of chart abstractors and systematic assessment of IRR between abstractors and validity of the abstracted data in stroke registries.

Administration of oxandrolone, a non-aromatizable testosterone analog, to children for 12 months following severe burn injury has been shown to improve height, increase bone mineral content (BMC), reduce cardiac work, and augment muscle strength. Surprisingly, the increase in BMC persists well beyond the period of oxandrolone administration. This study was undertaken to determine if administration of oxandrolone for 2 years yields greater effects on long-term BMC and bone mineral density (BMD). Patients between 0 and 18 years of age with ≥30% of total body surface area burned were consented to an IRB-approved protocol and randomized to receive either placebo (n=84) or 0.1 mg/kg oxandrolone orally twice daily for 24 months (n=35). Patients were followed prospectively from the time of admission until 5 years post burn in a single-center, intent-to-treat setting. Height, weight, BMC, and BMD were recorded annually through 5 years post injury. The long-term administration of oxandrolone for 16±1 months postburn (range, 12.1 to 25.2 months) significantly increased whole-body (WB) BMC (p<0.02) and lumbar spine (LS) BMC (p<0.05); these effects were significantly pronounced for a longer time in patients who were in growth spurt years (7 to 18 years). When adjusted for height, gender, and age, LS BMD was found to significantly increase with long-term oxandrolone administration (p<0.0009). Fewer patients receiving oxandrolone exhibited LS BMD z scores below −2.0 as compared to controls, indicating a significantly reduced risk for future fracture with oxandrolone administration. Long-term oxandrolone patients had significantly greater height velocity than controls throughout the first 2 years postburn (p<0.05). No adverse side effects were attributed to the long-term administration of oxandrolone. A comparison of the current patients receiving long-term oxandrolone to previously described patients receiving 12 months of oxandrolone revealed that long-term oxandrolone administration imparted significantly greater increases in WB-BMC, WB-BMD, and LS-BMD (p<0.05). In conclusion, the administration of oxandrolone for up to 24 months to severely burned pediatric patients significantly improves WB BMC, LS BMC, LS BMD, and height velocity. The administration of long-term oxandrolone was more efficacious than administration for 12 months. Additionally, fewer patients in the oxandrolone cohort met the diagnostic criteria for pediatric osteoporosis, pointing to a reduced risk for future bone fracture. This study demonstrates that administering oxandrolone for up to 2 years following severe burn injury results in greater improvements in BMC, BMD, and height velocity.