Outcome Analysis of Burns Patients in BICU

Outcome Analysis of Burns Patients in BICU Outcome analysis of burns patients after admission to burns intensive care unit in a tertiary regional referral centre Goh SY, Thong SY, Win MTM, Ng SY ABSTRACT Background: The clinical course of severely burned patients may be stormy and the prognosis tends to be poor in patients with multiple comorbidities and those with inhalational injury. The aim of this study is to develop an objective and reliable predictive model for mortality in patients with major burns. This will help us identify the important factors influencing outcomes and allows more evidence-based prognostication. Methods: Adult patients admitted to the burns intensive care unit (BICU) in a major tertiary referral center from 2008-2011 are selected. Demographic factors, types, severity and complications of burn injury as well as outcomes are reviewed. Results:In the 4-year period, 181 patients were admitted to BICU. Mean age (SD) was 41 (16) years old. Mean (SD) total body surface area burn was 37.2 (30.2%). Mortality was 39.5%. Mean (SD) length of stay in the BICU and hospital for patients who eventually survived were 8.4 (13.4) and 28.5 (37.9) days respectively. Lower airway burns has a significant relationship with the development of renal failure after multivariate analysis (Odds ratio 5.1, Confidence interval 1.1- 24.0). Greater total body surface burns, development of acute respiratory distress syndrome and older patients with more extensive burns predispose to mortality as shown in table 2. In our cohort of patients, the probability of death may be estimated by this equation: Probability of death= (1+ey)-1 y= -7.008+0.04(TBSA) +1.791(ARDS)*+0.054(Age+TBSA) *= ARDS (0=no, 1=yes) Conclusion: We have developed a predictive model for mortality in major burn patients. This may be useful in prognosis during early stages of care. Introduction Survival after burns injury has improved tremendously over the last few decadeswith the refinement of fluid resuscitation, better intensive care and early surgical excision1as some of the strategies that have significantly influenced patient outcomes. These advancements have contributed to lowering mortality rates in burns patients in Singapore to 4.5% between 2003-20052. Despite these advancements, however, overall mortality rates of patients with major burns remain high. Numerous factors such as age, percentage body surface area burns and inhalational injuries3 have been found to influence the prognosis and outcomes in this group of patients. The combination of these predictive factors into scoring systems that would yield an expected mortality rate for each given patient has been the subject of many studies4-6.However, most of these studies have not been performed or validated in our local population. A robust predictive model would be useful for clinicians as a more evidence-based approach for counselling and prognostication at an early stage of treatment. We can even plan further treatment and intervention based on prognosis and other clinical factors. A standardized model will also provide an opportunity for audit and a basis against which new treatment modalities may be compared. Therefore, the objective of this study was to identify the prognostic variables influencing outcome in patients admitted to our burns intensive care unit and to develop a predictive model for mortality in patients with major burns. Methods Clinical care The burns centre at the Singapore General Hospital is a major tertiary referral centre for burns injury in Singapore as well as the Southeast Asia region. Burn patients presenting at the Accident and Emergency department are assessed by the plastic surgerical team, who decide if the patient requires admission to the specialised burns unit or the burns intensive care unit. The extent and depth of burns were assessed and documented.All patients requiring intensive care, such as those with major burns, are haemodynamically unstable, or have sustained inhalational injury requiring mechanical ventilation, are managed by a team consisting of at least a plastic surgical specialist and an anaesthetist. These patients received fluid resuscitation according to the Parkland’s formula. Adequacy of fluid therapy was assessed by endpoints such as hourly urine output, arterial blood pressure and central venous pressure. Early enteral nutrition, mechanical ventilation and vasoactive support were initiated as required. Early surgery for escharotomy, burns excision and grafting were carried out as early as possible. Patients This study was approved by our centre’s institutional review board. The medical records of all burns patients admitted to the burns intensive care unit at the Singapore General Hospital over a 4-year period between January 2008 and December 2011 were reviewed retrospectively. Information including demographics, comorbidities, mechanism of injury, total body surface area (TBSA) burned, incidence of inhalation injury, complications such as organ failure, length of hospital stay and mortality were recorded and entered into a database. Statistical Analysis Statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS version 17, SPSS Inc., Chicago, IL). Data are presented as mean and standard deviationfor continuous variables and proportions for categorical variables. Univariate comparisons of proportions and means were respectively done using Chi Square test, Fisher exact test and t test. Logistic regression and linear regression analysis was applied to study the relationship between the variables and mortality and length of stay, respectively. Variables with a plausible relationship with mortality or p0.05. Results Patient profile During the 4-year study period, a total of 182 patients were admitted to the burns intensive care unit (BICU).These patient characteristics are presented in table 1. The mean age of these patients was 40.5 +/- 16 years old, with males comprising a larger percentage of the cohort (79.1%). Mean total body surface area (TBSA) burned was 37.2 +/- 30.2%. Most of the patients were healthy prior to their burns, with only a small minority having any significant medical issues. A high proportion of the patients suffered inhalational burns (83%). However, only 26 out of the 182 patients (14.3%) fulfilled the criteria for ARDS. Other significant patient characteristics and details of their burns injuries are listed in Table 1. Flame burn was the commonest injury etiology in our patient population (88.4%). Table 2 shows the mechanism of burn injuries suffered by our group of patients. Length of stay The mean length of stay was 20.9 days. The survivors spent a mean of 8.4 days in ICU, as opposed to 6.9 days for the non-survivors. The majority of patients who survived to discharge were discharged home (table 3). TBSA, albumin level and sepsis were found to be significant predictors of LOS, yielding a final predictive model of: LOS = 41.608 – 0.234(TBSA) – 0.919 (albumin) + 16.14 (sepsis*) Where *=presence of sepsis (yes=1, no=0) Mortality Out of the 182 patients, a total of 65 patients or 35.9 % did not survive the hospital stay. The mean age of these patients was 42.1 years. Mean TBSA involved was 66.8% (compared with a mean of 20.6% in the survivor group). In our analysis, we found that the non-survivor group had significantly larger TBSA burns (p To develop the predictive model, we analysed the variables in univariate analysis. Variables with a plausible relationship with mortality or p A predictive model for mortality was thus developed as follows: Probability of death = (1+ey)-1 Where y = -7.008 + 0.04 (TBSA) + 1.791 (ARDS)* + 0.054( Age+TBSA) * = ARDS (no=0, yes =1) Discussion In this study, we elucidated the risk factors that contribute to mortality in patients admitted to the BICU, and developed a predictive model for mortality incorporating these factors. Previous mortality studies have sought to establish prognostic variables associated with burn mortality. In 1961 Baux described in a French thesis a simple empiric formula, stating that mortality rate was the sum of age and percentage area burned7. Inhalational injury was then found to be an important predictive factor and this was included in a mortality probability equation reported by Clark et al in 19868. The abbreviated burn severity index (ABSI), which is in widespread use, assigns numerical values according to the severity of 5 prognostic variables (age, gender, inhalational injury, %TBSA and presence of full thickness burns). The sum of these variables yields a predicted mortality rate9. Similar predictive factors have been found to be relevant in several other studies3,10,11. However, these st udies generated highly variable predictive models, highlighting the need for individualised models for different patient groups. Our study is unique as it is one of only a handful of studies based on an Asian population2,12-14 , with even fewer attempting to develop predictive mortality models5. In addition, we only included burns intensive care unit patients in our study, as opposed to the entire burn population. Advancements in medical care and aggressive early excision and grafting of burns have led to a global reduction in burn mortality in recent times. In Singapore, the overall mortality for burns victims was found to be 4.5% between 2003 and 200512. This improvement has also been evident in severe burns victims, with mortality falling annually from 60% in 2000 to 30% in 20032. However, death rate remains high in this group of patients, and it is our aim to look at the outcomes and predictive factors determining mortality in this susceptible group, and to develop a clinically relevant predictive model targeted at them. Our study found that TBSA, age+TBSA and ARDS were significant predictive factors affecting mortality in our ICU patients. Inhalational injury, generally accepted as a prognostic factor8,9, was not found to be significantly associated with death in our patient group. There could be several explanations for this finding. In our series, 151 or 83% of our patients were diagnosed with inhalational burns. This is a very high percentage compared to most of the other studies, though it is not entirely surprising. Our patient cohort consisted entirely of ICU patients. This unique group of patients have either sustained major burns or inhalational burns that have required ventilatory support. . The remaining 17% of patients that might have been in ICU due to reasons other than inhalational injuries may not have been sufficient in number to demonstrate a survival advantage, if any. Secondly the lack of universally accepted diagnostic criteria means that the diagnosis of inhalational injury can vary widely between different institutions and intensivists, using either clinical examination or fibreoptic bronchoscopy, or a combination of both. Hence it has been suggested that, the need for invasive ventilation, the determination of which is far less complicated than the diagnosis of inhalational injury, may be a better marker for mortality risk6. In our study, we found that the presence of acute respiratory distress syndrome (ARDS), a common complication associated with major burns or severe inhalational injury, was directly associated with death. This could be an indication that the severity of inhalational injury, rather than the presence of it, may be a more suitable prognostic indicator for death, particularly in the group of patients requiring intensive care management. Since this is a retrospective study, we were not only able to collect data relating to the patient’s characteristics at presentation, but also susbequent clinical data as treatment progressed, such as development of ARDS, sepsis and renal failure. Clearly these factors are important as response to therapy is a vital determinant to patient outcomes. However, inclusion of these variables may not be possible at patient presentation, the point at which prediction of mortality is sometimes vital for determining the direction and aggressiveness of therapy. Perhaps future prospective trials can look at determining predictive factors that influence mortality at various stages of treatment, creating a superior prognostic tool with which we may advise patients and families, guide therapy and perform internal audit and research. Clinicians utilising any kind of predictive model to estimate mortality probability in the clinical setting should always proceed with caution. These may be used as a tool to aid clinical decisions regarding treatment but should not replace sound clinical judgment. Neither should the outcomes be judged solely upon whether the patient lives or dies, without scant consideration for the quality of life after the hospital stay. These endpoints are a lot more difficult to assess, and in the absence of a standardized tool the incorporation of quality of life indicators into prognostic scoring systems may still be a long way away. Conclusion In our study, we have developed a predictive model for mortality in our cohort of burn patients admitted to the burns intensive care unit. The next step would be to validate the model in future prospective studies. A validated model can potentially help teams involved in tough clinical decisions to prognosticate and formulate treatment plans for severely burned patients. It also serves to show that further studies need to be done to validate and come up with a more robust model. We did not find a significant relationship between inhalational injury and mortality in our study, a finding consistent with several other studies.

Death Penalty Essay -- essays research papers fc

Thesis It is more reasonable to utilize the death penalty than to abolish it. The death penalty should not be abolished because (1) it deters people from committing murder and (2) because the death penalty gives peace of mind to the victims and their families and puts an end to the crime.  Ã‚  Ã‚  Ã‚  Ã‚   Arguments for the thesis (1) The death penalty should not be abolished because the fear of the highest form of punishment will keep potential victims alive. (2) The death penalty should not be abolished because the families of the victims can only begin the healing process once the murderer is put to death. Response to objections to the thesis (1) Objection: The death penalty should be abolished because even the highest form of punishment will not remove the evil from society. Response: If the death penalty was abolished, the convicted murderer has the potential to escape and kill again. This will spread more evil and give the option to kill again to the murderer. (2) Objection: The execution of a convicted murderer will never bring the victims back to life. Therefore it serves no purpose other than to kill.  Ã‚  Ã‚  Ã‚  Ã‚   Response: Resurrection has never been the purpose of the death penalty. The family members just want to start healing and they can’t while the perpetrator is still alive. Bibliography Van der Haag, Ernest and John P. Conrad, The Death Penalty: A Debate (New York: Plenum Press, 1983). Arlen Specter, â€Å"Congress must make Death Sentences Meaningful Again† (Human Events, July 1994). Hugo, Adam Bedau, Ed., The Death penalty in America: Current Controversies (New York: Oxford University Press, 1997) Blumstein, Cohen, Nagin, Deterrence and Incapacitation (National Academy Press January 1978) It is more reasonable to utilize the death penalty than to abolish it. The death penalty should not be abolished because (1) it deters people from committing murder and (2) because the death penalty gives peace of mind to the victims and their families and puts an end to the crime. The death penalty deters some people from committing heinous crimes and thereby also saves human lives. Not everyone will be deterred from committing heinous crimes because of the death penalty. However, since the death penalty is the highest penalty for crimes it will obviously evoke the most fear in a human being. This fear will save... ...rt the healing process. If a state governed by law is to be able to show warmth, compassion and peace of mind to victims and their families, then the death penalty is the most effective way to bring this about. The argument to the above is that the death penalty does not bring back any victim to life, therefore, unnecessary. Just because someone has taken a life, it doesn’t mean that the convict’s life should also be taken. Is it fair to take a bad situation and make it worse? The death penalty will never sweep away the emotions and feelings of grief that the relatives and friends feel. Murdering the convicted murder would only cause more grief for his family, therefore, over time, grieving would become commonplace. Resurrection has never been the purpose of the death penalty. It is understood that the death penalty will not totally take away the emotions and feelings of the relatives, however the death penalty will ease those pains. The grief and despair would be considerably heavier to carry if the relatives knew that the perpetrator was only sentenced to prison and would be released after a period of time. Therefore, I feel that the death penalty will never become unnecessary.

The importance of music

Music first formed in ancient time and continued to develop simultaneously with civilization. It is said that without music, our world would become boring. Why music is so Important? Why many people spend a lot of time on listening to music? In fact, music affects us more than we know. Music plays Important roles in our life: It connects people, entertains us and has other uses In particular times. First, music connects people. Different ages, different classes of people come closer getting know each other through music.Specifically, many international encores was held worldwide in a Joint effort to exchange culture and struck up or develop friendship. The countries, as a result, can lead to a multilateral development agreements. Moreover, the people in those countries can be pleased thanks to the influence of music idols. In addition, music can heal the breach between people. It reduces seriousness among those who are in debates. Familiar melodies bring back their memories, throw th em back to their happy time In the past and it reconnects them In spiritual level. Besides, music encourages humanitarian actions.People often hold charity concerts and music makes them easy to emphasize with unfortunate lives. In other words, music brings us together. Second, music entertains us In many ways. After long hours working hard, listening to our favorite rhythm can help us relax or even stimulate our brain in order to keep on working efficiency. Furthermore, after a stressful day, music is one of the best ways to entertain. It can be exciting, gentle or soft, depending on the listeners' sense. An amazing way to enjoy music is to attend concerts, theaters or just turn on TV and sites to our favorite songs.Moreover, if you can play musical instruments, it will be the best way to enjoy music. Playing music by ourselves, we understand completely the song and get closer to the singer. Music is an important part of our life. Entertainment Is the thing cannot be denied when we talk about music. Finally, music also has many good uses to people. Apparently, with music, we can express ourselves, our feeling, our thought and our emotion. For example, when we are sad, we prefer to listen to sad song like † unchain melody † In order to show our sadness. Moreover, music can create particular atmosphere for different situation.For instance, people prefer to open solemn music in some formal occasions. One more use of music is that it builds up nation esteem. Specifically, when listening to nation anthem,we are proud of our country more than ever. In short, music has many incredible uses that strongly affect our thoughts, our emotion and our work. In summary, music plays important roles in our life. Not only are the young people influenced by music but also the old can't help enjoying the rhythm. Music relaxes us, assists us with many good things but its uppermost effect Is to bring us together.It is hard for us to Imagine a world without music, that wo uld be boring and full of sadness. The importance of music By painlessly 2 is so important? Why many people spend a lot of time on listening to music? In fact, music affects us more than we know. Music plays important roles in our life: it connects people, entertains us and has other uses in particular times. Their memories, throw them back to their happy time in the past and it reconnects them in spiritual level. Besides, music encourages humanitarian actions. People often Second, music entertains us in many ways.After long hours working hard, listening to amazing way to enjoy music is to attend concerts, theaters or Just turn on TV and Entertainment is the thing cannot be denied when we talk about music. Finally, music we prefer to listen to sad song like † Unchain melody † in order to show our sadness. Influenced by music but also the old can't help enjoying the rhythm. Music relaxes us, assists us with many good things but its uppermost effect is to bring us together . It is hard for us to imagine a world without music, that would be boring and full of

Write IEP Goals for Healthy Student Work Habits

When a student in your class is the subject of an Individual Education Plan (IEP), you will be called upon to join a team that will write goals for him or her. These goals are important, as the students performance will be measured against them for the remainder of the IEP period and their success can determine the kinds of supports the school will provide.   SMART Goals For educators, its important to remember that IEP goals should be SMART. That is, they should be Specific, Measurable, use Action words, be Realistic and theyre Time-limited. Here are some ways to think about goals for children with poor work habits. You know this child.  She or he has trouble completing written work, seems to drift away during oral lessons, and may get up to socialize while children are working independently. Where do you start setting the goals that will support her or him and make them a better student? Executive Functioning Goals If a student has a disability such as ADD or ADHD, concentration and staying on task wont come easily. Children with these issues often have difficulty sustaining good work habits. Deficits such as this are known as executive functioning delays. Executive functioning includes basic organizational skill and responsibility. The purpose of goals in executive functioning is to help the student keep track of homework and  assignment due dates, remember to  turn in assignments and homework, remember to bring home (or return) books and materials. These  organizational skills lead to tools to manage his daily life.   When developing IEPs for students who need help with their work habits, it is important to remember to key in on a few specific areas. Changing one behavior at a time is much easier than focusing on too many, which will be overwhelming for the student. Sample Behavioral Goals Focus attention with minimal supervision or intervention.Refrain from distracting others.Listen when directions and instructions are given.Identify what is needed each work period and each day for homework.Be prepared for assignments.Take the time to do things right the first time.  Think things out on your own before asking.Try things independently without giving up.Work independently as much as possible.Apply successful strategies when involved in problem-solving.Be able to re-state problems, instructions, and directions to help with understanding the task at hand.Take responsibility for all work being done.Participate fully in group situations or when called upon.Be responsible for self and belongings.Remain positive when working with others.Cooperate in both large and small group settings.Be considerate of the opinions of others.Seek positive solutions for any conflicts that may arise.Always follow the routines and rules. Use these prompts to craft SMART goals. That is, they should be achievable and measurable and have a time component. For example, for the child who struggles with paying attention, this goal incorporates specific behaviors, is actionable, measurable, time-bound, and realistic:   The student will attend (sit still with eyes on the teacher, keeping their hands to themselves, using a quiet voice) to a task during large and small group instruction for a ten-minute period, with no more than one teacher prompt in four out of five trials, to be measured by the teacher. When you think about it, many of the work habits lead to good skills for life habits. Work on one or two at a time, obtaining success before moving to another habit.

Internet Privacy Essay - 699 Words

Why should I worry about privacy and security? Im not a criminal or a terrorist. Ive got nothing to hide. These are things that most people think. They also believe the internet is much more secure and that their personal information is only available to them, whereas this is actually quite wrong. There are more reasons to want to protect your privacy than can be named. The important principal is that you have a right to privacy as long as that right is used within the bounds of the law. Seeking privacy should not make you feel guilty. Privacy should be expected, and demanded. The reasons might be as simple as preserving your right to express unpopular opinions without being subjected to persecution, or as serious as communicating†¦show more content†¦It can be quite simple for someone to intercept your messages or information if they want it. This may be just an administrator of your ISP or your office network. Or it might be a business competitor, legal foe, or government agency, with much more serious intentions. There are an abundant means available to protect online privacy. Some are large and complex while others are extremely simple. The important fact is that some methods are almost totally lacking in security while others are practically bulletproof. It is an all too common misconception that anonymity equals privacy. Anonymity and privacy may be related, but their significance is quite different. Do you wonder what other people know about you? Cookies are available on certain websites, and these small files are placed on your computer and record data which most often contains information that the user would rather be kept secure. Information including passwords, credit card numbers and where the user has been. There are hundreds of web-based email services that appear to offer anonymity. Few really do. These include names such as Hotmail, Yahoo, Excite and many more that could be listed. In each of these cases, the user is allowed to create a personal username that he uses for his messages. Unfortunately, through sign-up procedures and logging, it is amazingly simple to determine your ISP, and even yourShow MoreRelatedGoogle and Internet Privacy717 Words   |  3 PagesGoogle and Internet Privacy In this exercise on ethics and privacy policy we focus our studies on an oft occurring situation in offices that have multiple employees sharing office resources that may lead to intrusive instances. The case refers to a couple of employee’s complaints of unwarranted pop-ups on their computers from unsolicited advertisers. 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But, the use of cookies to track users browsing habits is becoming a concern of many internet users. These concerned people are beginning to think of cookies as an invasion of privacy. Companies with web sites can use cookies to track what sites you visit frequently and then select specific

Customer Service For Services For Yelp Essay - 2248 Words

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I would not use the word fear; however, organizations - and consumers - should be cognizant of such websites and the impact that the sites can have on any type of business. Give an example of a corporate website where negative and/or uncomplimentary messages have been posted. The importance of relying on scholarly - peer reviewed - articles and journals become clearer withRead MoreMobile Phones : The First Form Of Communication1565 Words   |  7 PagesIntroduction - Cory Paradis As cellphones have advanced, methods of communication beyond the standard phonecall have appeared on the devices as well, such as email support and SMS (Short Message Service, colloquially known as texting). With the introduction and increased proliferation of smartphones, defined by the Oxford Dictionary as mobile phones [...] with an operating system capable of running downloaded applications[1], an even greater variety of communication methods have developed using

Essay Violence In School Example For Students

Essay Violence In School Violence in schools is a great concern in our society. The concern is heightened by the abundance of media coverage on a number of recent school shootings. With all of the news clips, sound bites, and Internet coverage swirling around in our heads, one might conclude that children are more violent today, than they were in recent years. But, school violence is not a new issue for the nineties; School violence has been around since the1950s, but then it was more an issue of juvenile delinquency than violent behavior. The difference between the two generations is that today student conflicts are more likely to be solved with the use of weapons. The fact is a gun is much more intimidating than a fist. There is nothing scarier than arriving at school afraid of what may happen next. Many students are faced with this problem everyday. Children should feel safe when they walk into school. Many people use violence as an expression to release feelings of anger or frustration. They think there are no answers to their problems and turn to violence to express their out of control emotions. Others use manipulation as a way to control others or get something they want. Violence is a learned behavior. Like all learned behaviors, it can be changed. This isnt easy, though. Since there is no single cause of violence, there is no one simple solution. The best you can do is learn to recognize the warning signs of violence and to get help when you see them in your friends or yourself. Teachers tend to believe that school violence is a result of sociological factors such as: lack of parental supervision, lack of family involvement and exposure to violence in the mass media. These factors could be traced to high divorce rates, both parents working and high availability of mass media, e.g. television, Internet, ect.Students who live in fear of violence, witness violent acts, or become victims of violence suffer an array of short-term and long-term consequences emotionally and physically. They have been found to be at greater risk for low school performance, absenteeism, truancy, school dropout and delinquency. In fact, research has shown that juveniles who are victimized, or who repeatedly witness violence, and do not receive immediate support in understanding and dealing with it are at higher risk of using violence as a means of dealing with their own conflicts; thus repeating the cycle of violence. Schools are not doing enough to protect students and other school personnel. Curing social ills could take a long time, so I propose a high security approach to the problem. The community may find this expensive and students find it oppressive, but how many more people have to die? I propose the following strategy: Police officers in every school; Metal detectors at each doorway; Some type of dress code-banning ?big clothes? where weapons can be hidden; Hall monitors- hallways, doorways, restrooms and cafeterias; Train certain school personnel in weapon usage. Allow them to carry and store weapons on campus. If students knew someone else on campus had a gun to protect students, they may think twice about bringing one to school. This may sound severe, but this is a direct approach to the problem. Additional discipline is needed in order to stop school violence. We need more discipline in the family, in school, and even in public. We need to educate children that their actions do have consequences. As our countrys morals keep declining and the murder rate continues to rise in schools, we will still be blaming our problems on anything but ourselves.