bluuebunny/crossref_metadata_2025 huggingface dataset:
20 Autologous Meshed Split Thickness Graft Healing in Interstice versus Grafted Sites: A Histological Characterization
Authors: Oliver Mary A , Carney Bonnie C , Keyloun John W , Jimenez Lesle M , Moffatt Lauren T , Shupp Jeffrey W
Published: March 2022

Introduction

Autologous skin grafting is a common technique used in the treatment of full thickness (FT) wounds to aid in healing, wound closure, and reducing the likelihood of developing hypertrophic scarring. Meshed split thickness skin grafts (mSTSG) which contain portions of the dermis and epidermis are the gold standard for the treatment of FT wounds because they allow for expansion of skin taken from a relatively small donor site. It has largely been hypothesized that in mSTSG skin progenitor cells migrate from the edges of healthy donor tissue to aid in healing the interstices created by meshing. For this reason, meshed wound healing is not homogenous as interstice and meshed sites display distinct healing characteristics. This study aims to characterize the differences between interstice and grafted site healing.

Methods

Wound healing was evaluated in vivo using Duroc pigs. In this model, 4 animals had 10.16 cm by 10.16 cm full-thickness burns created on bilateral flanks for a total of 12 wounds. On day 2, the burns were excised down to subcutaneous tissue, mSTSG was harvested, meshed 4:1, and applied to the prepared wound beds. Wounds were photographed and sampled on days 5, 9 and, 15. Punch biopsies from either the grafted area or interstice area were taken at each time point, processed, and imaged. Images were used to quantify epidermal and dermal thickness, cellularity, and rete ridges.

Results

Epidermal thickness at day 5 in interstices was significantly thinner than in graft (1.73±4.33µm vs. 75.7±66.1µm, p< 0.05). By day 9, interstice epidermal thickness was comparable to graft thickness (194.9±157.7µm vs. 199.5±117.7µm). On the other hand, dermal thickness was elevated in the interstice at days 9 (1850.4±642.0µm vs. 1277.6±652.0µm, p< 0.05) and 15 (2469.9±626.14µm vs. 1660.7±674.6µm, p< 0.01) to a significant degree. Cellularity was greater at all time points in the interstice compared to the grafted sites. Similarly, rete ridge ratios (RRR) were significantly greater in the grafted areas at day 5 (0.0±0.0µm v.s. 1.0±0.7µm, p< 0.01) and day 9 (1.32±1.2µm vs. 1.9±0.45µm, p< 0.05).

Conclusions

These data show that within a grafted burn wound, healing is a dynamic and heterogenous process when looking at interstice and graft sites, respectively. Grafted sites were thinner throughout, showed decreased inflammatory cell infiltrate, and exhibited higher RRR. Thicker tissue layers and upregulated cellularity in interstices point to a wound healing trajectory that is slower than grafted sites, even by the time wounds are fully re-epithelized.
38 Utilizing an Implementation Science Framework to Design a Burn Resuscitation Bundle in a Resource-limited Setting
Authors: Mehta Kajal , Lee Joohee , Mesic Aldina , Yadav Manish K , Shrestha Raslina , Poudel Kiran , Gyawali Prakriti , Pham Tam N , Rai Shankar , Stewart Barclay T , Nakarmi Kiran K
Published: March 2022

Introduction

Protocolized burn resuscitation algorithms with hourly, closed loop feedback, have reduced instances of over- and under-resuscitation and improved outcomes in high income countries. However, a “know-do” gap exists as this practice has yet to be adopted in many low- and middle-income countries (LMIC). We aimed to describe the change management process of the development and implementation of a contextually driven protocolized burn resuscitation bundle at a tertiary burn center in an LMIC using an implementation science framework.

Methods

We applied strategies from the Expert Recommendations for Implementing Change (ERIC) for the design and implementation of a burn resuscitation bundle at a major burn center in an LMIC, over a 9-month period. Semi-structured focus group discussions (FGD) were conducted with stakeholders to understand facilitators and barriers to developing and using the protocol, with iterative feedback used to inform and adjust the protocol and documentation tools. Responses were analyzed using content analysis and particularly unique and useful responses were highlighted.

Results

Stakeholders identified resource constraint-related concerns about the feasibility of an hourly IV resuscitation protocol and reached consensus on performing 2-hourly assessments and fluid adjustments. Corresponding documentation tools were developed and iteratively adjusted. Several initial barriers to adoption and institutionalization were encountered. ERIC strategies used to promote intervention uptake included simplification and visualization of the protocol, identification of a project champion, development of educational materials for multiple cadres (e.g., nurses, physicians, health assistants), use of chain of command to enable change and accountability, utilizing institutional branding and ultimately obtaining endorsement by the center’s leadership (Table 1). Post-implementation FGD with stakeholders revealed high levels of acceptance, utilization and adherence of the protocol bundle, with occasional opportunities for improvement identified in protocol completeness and accuracy.

Conclusions

Adoption of change in clinical resuscitation practice in a resource-constrained setting required a contextually driven, multi-faceted approach led by a team of change champions and leaders. The ERIC framework allowed for an iterative approach to prioritize stakeholder engagement and feedback, in order to implement a protocolized IV resuscitation bundle in a LMIC.
42 The Overt Pulmonary and Systemic Pro-inflammatory Response After Burn and Inhalation Injury Is Mtor Dependent
Authors: Hall Hannah R , Mahung Cressida , Seim Roland F , King Booker , Wallet Shannon , Maile Robert
Published: March 2022

Introduction

Severe burn injury can lead to local and systemic activation of the innate immune system which can cause a dysfunctional and overt pro-inflammatory response, resulting in inflammatory complications and organ dysfunction. If there is an inhalation injury concomitant with burn, patients have a 3.6 times higher mortality rate and greater than 70% chance of developing secondary respiratory complications. Previous work has shown that the Mechanistic/ Mammalian Target of Rapamycin (mTOR) pathway is involved in signaling neutrophil activity in burn patients. Antagonists of mTOR stimulation represent possible immunomodulatory therapies. However, it is unclear if mTOR plays a role in the pulmonary distress seen after combined burn and smoke inhalation (B+I) injury. The goals of this study were to 1) characterize a novel mouse model of combined B+I injury and 2) investigate the role of mTOR in the pro-inflammatory response after B+I injury.

Methods

We built upon our pre-established 20% total body surface area cutaneous burn mouse model by adding smoke inhalation injury and treating mice with rapamycin, a mTOR-specific inhibitor. In brief, mice were anesthetized before receiving controlled B+I, burn only, or sham injury. After resuscitation, they were given morphinated water for 24 hours before euthanasia and tissue collection. RNA and whole cells were extracted from lung and spleen tissue for analysis by Nanostring and Flow Cytometry, respectively. Fluid within the lung (bronchoalveolar lavage, BAL) and peripheral blood plasma were collected for pro-inflammatory cytokine quantification via magnetic bead multiplex assays.

Results

Wildtype female C57BL/6 mice that underwent B+I injury exhibited elevated levels of protein, macrophages, and neutrophils in the lung cavity compared to burn alone. In addition, 29 genes were significantly differentially expressed in the lung tissue after B+I, suggesting that inhalation elicits a unique response when compared to burn alone. In the peripheral blood, B+I mice have a >4 fold increase in IL6 and 3 fold increase in MCP-1 pro-inflammatory cytokine levels. When we examined the role of mTOR in B+I injury, we found that pre-emptive rapamycin treatment leads to a reduction in peripheral blood pro-inflammatory cytokine levels, namely MCP1, TNFa, IL10, and IL2, and an increase in pro-inflammatory cytokine IL2 in the lung cavity. Rapamycin significantly affected expression levels of 46 genes in the lung and 36 genes in the spleen, indicating an mTOR-dependent response to inhalation injury.

Conclusions

In conclusion, these data describe a valuable mouse model of B+I with inhalation-specific immune phenotypes and implicate mTOR in the inhalation-induced hyper pro-inflammatory response.
49 Bromelain Based Enzymatic Debridement of Pediatric Deep Burns: Top Line Results of a Multicenter RCT
Authors: Shoham Yaron , Narayan Ravi P , Monstrey Stan , Hoeksema Henk , Lewis Giavonni M , Jha Manoj Kumar , Larson Shawn D , Kravtsov Oleksii , Hanganu Elena M , Gozar Horea G , Pham Tam N , Singer Adam , Sheridan Robert L , Glat Paul M , Sander Frank , Bhavsar Dhaval , Wibbenmeyer Lucy
Published: March 2022

Introduction

Bromelain based debridement (BBD) of deep burns with a concentrate of proteolytic enzymes enriched in Bromelain is approved for use in adults in several regions worldwide. Children are a large part of the patient population in many burn centers around the world. Clinical trial experience and off label reports point to BBD safety and efficacy in children as well. The aim of this study was to further assess the safety and efficacy of BBD in children, in efforts to support regulatory approval for the use of BBD in children.

Methods

One hundred and forty five children aged 0-18 years old suffering from deep thermal burns between 1-30% TBSA were enrolled in a multicenter, multinational, open label, randomized, controlled phase III study. Seventy two children were randomized to eschar removal with BBD and 73 children to standard of care (SOC) surgical and/or non-surgical eschar removal methods, at the investigators' discretion. Patients who did not achieve complete eschar removal after BBD application were rescued with SOC eschar removal methods. Wound care after achieving complete eschar removal was according to routine methods, at the investigators' discretion. Patients are currently in stages of long term follow-up, planned for a duration of >2 years. This abstract reports the top line results of the study including the first year of follow-up.

Results

Baseline characteristics were similar between the arms. The median age was 3.4 years in the BBD arm and 3.9 years in the SOC arm. The average burn area was 7.0±4.9 %TBSA in the BBD arm and 6.2±4.8 %TBSA in the SOC arm. The study met all 3 primary endpoints: Median time to complete eschar removal was 1 day for BBD and 6 days for SOC (p< 0.001), the percent wound area excised in order to complete eschar removal was 1.5% for BBD and 48% for SOC (p< 0.0001), and the MVSS scores at 12 months were 3.83 for BBD and 4.86 for SOC (non-inferiority endpoint). Secondary endpoints demonstrated 8.3% incidence of surgical excision to complete eschar removal for BBD and 64.4% for SOC (p< 0.0001), mean eschar removal associated blood loss of 32±284ml for BBD and 202±409 for SOC (NS), a 25.9% incidence of autografting in deep partial thickness wounds for BBD and 37.7% for SOC (p=0.054), and a mean percent area of deep partial thickness wound autografting of 15.9±38.6 for BBD and 22.8±43.7 for SOC (NS). Safety endpoints demonstrated a non-inferior time to complete wound closure (median 32 days for BBD, 34 days for SOC) and no significant safety issues were demonstrated during the study.

Conclusions

BBD was shown to be a safe and effective debridement agent in pediatric burns.
64 Community Level Disadvantage Negatively Impacts Return to Work After Burn Injury
Authors: Murphy Schachia , McMullen Kara , Carrougher Gretchen J , Mason Stephanie A , Carter Damien W , Stewart Barclay T , Thompson Callie M , Suman-Vejas Oscar E
Published: March 2022

Introduction

The loss of income from injury, additional health care expenses, and inability to return work can lead to unsatisfactory outcomes. Community level disadvantage (e.g., low high school completion, low home ownership, low income) are more common among minority groups. We hypothesized community level disadvantage would negatively impact the ability to return to work after burn injury. This could serve to identify patients who need focused social, vocational, and financial support during rehabilitation.

Methods

Data from adult participants in a large multicenter database from 1998-2021 were linked by zip-code to three multi-domain community level-indices: i) Distressed Communities Index, ii) Social Vulnerabilities Index (SVI), iii) Social Deprivation Index (SDI). Cohort characteristics, the distribution of each index within cohort, and days to return to work were described. Fit and strength of association between the indices and return to work was assessed with multi-level logistic regression models. A non-responder analysis examining demographic and clinical differences between was performed using Chi-square tests and Wilcoxon rank sum tests to understand potential bias in the findings.

Results

A total of 1960 participants provided both zip code and employment data 6 months after injury. 75% of participants were male. Mean age was 39. Race/Ethnicity Data: 81.4% identified as White, 11% Black, and 7% as “other” race; 84% of the participants as non-Hispanic or Latino. Median burn size was 20% TBSA (IQR 0.1-95.0), and length of hospitalization was 30 days (IQR 0-379). Of the community indices tested, both DCI and SVI were associated with return to work with DCI having the strongest association with return to work after injury, irrespective of indices. However, when DCI and SVI were included in the model to represent community disadvantage, the impact of race on return to work was less. Participants who did not provide employment information were younger, sustained larger burn sizes, and had longer LOS compared to those who did.

Conclusions

DCI and SVI are associated with return to work after burn injury and can be used to focus limited social, vocational, and financial services. Minoritized participants were less likely to return to work but they live in communities with greater disadvantage (e.g. fewer employment opportunities), which highlights the public health impacts of structural racism.
68 The Association Between Body Mass Index and Physical Function in Adult Burn Survivors
Authors: Palackic Alen , Rontoyanni Victoria G , Branski Ludwik K , Duggan Robert P , Schneider Jeffrey C , Ryan Colleen M , Kowalske Karen J , Gibran Nicole S , Stewart Barclay T , Wolf Steven E , Suman-Vejas Oscar E , Herndon David
Published: March 2022

Introduction

An area of rehabilitation research in burns is the impact of co-morbidities. Obesity is one of these, is an increasing public health concern, and its role remains controversial regarding burn injury and physical recovery. Our aim was to evaluate associations between body mass index (BMI) as a measure of obesity, at discharge and self-reported physical function (PF) during recovery of adult burn survivors.

Methods

This study included data that was collected by four American Burn Association-verified burn centers, which contribute to the Burn Model System National Database project. The data included BMI obtained at hospital discharge and self-reported Patient-Reported Outcomes Measurement Information System (PROMIS)-29 PF-mobility and upper extremity scores assessed at 6-, 12-, and 24-months after burn. Mixed linear models for repeated measures and regression models were used to assess associations between BMI and PROMIS-29 PF scores over time. Values are expressed as means ± SD. Significance was set at p< 0.05.

Results

A total of 502 adult patients aged 47 ± 16 years were included, with mean total body surface area burned (TBSA) of 17 ± 18 % (range; 1.0-88%) and mean BMI of 23.1 ± 5.4 kg*m-2 (range; 14.0-64.7 kg*m-2). We found no significant effect at 6 months (beta=-0.045, p= 0.54) nor at 12 months after injury (beta=-0.063, p= 0.44) when adjusted for age, burn size, and sex, however, BMI at discharge had a significant negative effect on self-reported mobility scores 24 months after injury (beta=0.218, p=< 0.05).

Conclusions

Increased weight (i.e. BMI) at discharge was negatively associated with PF during recovery. Benefiting from a large sample size, our analysis suggests that long term recovery and restoration of PF in adult burn survivors is compromized by excess body weight.
76 A Retrospective Review of Factors Influencing Return to Work/school in Burn Patients
Authors: Foster Kevin N , Islas Claudia , Kabir Samin , Richey Karen
Published: March 2022

Introduction

Treatment and time to healing for burn injuries is largely dependent on the depth of the burn, location, and size. Treatment varies and can include any or several forms of dressings, surgery to remove eschar, allografting, autografting, depending on the depth of the burn. Hospitalization time ranges from days to months. Once discharged, patients continue to follow-up with burn specialists to ensure burns are healing properly. The time it takes a burn patient to return to work or school differ and can be dependent on many factors including personal choice. The objective of this study was to assess the time it took patients to return to work or school following burn injuries and help identify potential factors influencing their return time.

Methods

A retrospective chart review of patients aged > 5 years, with TBSA > 10%, requiring hospitalization for > 7 days in a two-year span (2018-2019) was performed. Patients who did not report employment during admission and those who expired during hospitalization were excluded. IRB approval was obtained to contact patients via telephone who did not report a return to work or school date during their outpatient follow-up.

Results

There were a total of 1579 burn admissions from 2018-2019, 93 of those patients met final protocol criteria. Seventy-four of those patients returned to work/school (RTW), and nineteen did not return to work/school (N-RTW) as of chart review date. The average total body surface area (% TBSA) for RTW was 18.30 vs. 33.08 for NRTW (p=0.0002). The average length of stay (LOS) for RTW was 23.55 vs. N-RTW 51.15 (p=0.0102). Exact return to work/school dates were obtained from 67 patients. The average length of days to return to work/school (n=67) was 102.19 post discharge, the minimum was 2 days, and the maximum was 785 days. There were 9 patients in the N-RTW group who filed for disability.

Conclusions

Results suggest the average days per %TBSA it takes for burn patients to return to work or school is 5 days. Additionally, larger %TBSA burned and longer hospital LOS also adversely affected return to work. Additional studies are needed to identify additional factors influencing return to work and to identify methods to hopefully improve the ability to return to work.
99 Feasibility of Deep Learning-based Automatic Myofiber Size Measurement for Burn-induced Muscle Wasting and Its Reversal
Authors: Morinaga Hiroyuki , Sugawara Yoh , Chen Jingyuan , Martyn Jeevendra , Yasuhara Shingo
Published: March 2022

Introduction

Patients with major burn injury (BI) often develop muscle wasting (MW) and mitochondrial dysfunctions (MD), which affect their prognosis. We have recently shown that auto/mitophagy response is defective in BI model and can be mitigate by trehalose treatment. Though auto/mitophagy is widely accepted as the quality control (QC) system of cellular components including mitochondria, the relationship among MD, auto/mitophagy response defect, and MW was unclear. Furthermore, to evaluate MW precisely by morphometric analyses was difficult, due to the ehavy workload of counting the size of muscle cross sectional area manually and analyzing the data. Thus, we have set up a streamline of whole section image capturing, analyzing with cutting edge deep learning-based method, processing it via image J-based program. Using this system, we have tested the efficacy of trehalose on mitigating MW in BI-treated mice.

Methods

First, the effect of auto/mitophagy modulator on normalizing defective auto/mitiophagy maturation was confirmed by in vivo microscopy of tfLC3-expressing mice with BI (30% BSA) or sham-burn (SB) control. A mitophagy inducer, CCCP was injected to induce mitophagy, and the auto/mitophagosome maturation was monitored with or without trehalose treatment. In a separate experiment, tibialis muscles were harvested at post-burn day (PBD)-7, with or without trehalose treatment (2g/kg/day, i.p.), cryosectioned, and stained by anti-laminin antibody. The entire tissue cross-sectional microscopic images were captured, fed into a cellpose, and processed in ImageJ and Prizm for automatic calculation of the cross sectional area (CSA).

Results

In vivo microscopic monitoring of auto/mitophagosome maturation revealed BI-induced maturation defect when treated by CCCP, which was rescued by trehalose treatment. Next, with MW analysis experiment, cross-sectional morphometric analysis of tibialis anterior myofibers showed a typical bi-phasic pattern of CSA distribution (large size population and small size population) in the control group. BI treatment showed a significant CSA decrease in both populations, which was effectively treated by trehalose. The average CSA was as follows (1843.0, 1245.3, 1683.9 for SB control, BI, BI+trehalose, respectively, in micron^2), and in accordance with manual counting measurement.

Conclusions

Normalizing defective auto/mitophagy response was shown an effective therapeutic approach to mitigate BI-induced MW. Deep learning-based size counting method is a feasible technique for a systematic MW analysis. Note that in our data, trehalose does not function in increasing the basal level of autophagy, but it mitigates the defective response of auto/mitophagy to the auto/mitophagic stimulation, by normalizing the maturation process.
104 Parkin-independent Pathway of Mitophagy as a Potential Target Mitochondrial Dysfunctions in Burns
Authors: Chen Jingyuan , Sugawara Yoh , Morinaga Hiroyuki , Martyn Jeevendra , Yasuhara Shingo
Published: March 2022

Introduction

In many critical illnesses including burn injury (BI), muscle wasting (MW) with mitochondrial dysfunction (MD) leads to poor prognosis. Disturbed mitochondria can normally be turned over by autophagic degradation of mitochondria (mitophagy). We have previously observed that BI causes disturbed mitophagy response in skeletal muscles both in vivo and in the cultured myocytes, a potential mechanism for BI-induced MD. These previous findings have lead to the expectation that augmenting mitophagy will rescue mitochondrial functions and can help treating the BI-induced MW and MD. There have been, however, limited research tools to specifically intervene (or augment) mitophagy. In the current study, we have established mitophagy-compromised cell strains by CRISPR/Cas9-mediated knocking out of BNIP3L, a pivotal molecule mediating parkin-independent mitophagy induction. Deferiprone (DFP), a recently established mitophagy inducer, had previously been known to exert cellular and organ protective functions, but the mechanisms of its beneficial effects were not investigated in detail. Nor has its efficacy been tested on BI-induced MD.

Methods

First, whether DFP stimulated mitophagy induction causes translocation of mitophagy markers into mitochondrial fraction, was tested by Western Blotting on the WT C2C12 cells against Parkin/PINK1- and BNIP3L- pathway molecules. Next we established BNIP3L knockout C2C12 myoblast cell like by CRISPR/Cas9-mediated gene deletion. Using both WT and BNIP3L knockout (KO) cell lines incubated in the BI or SB serum (from 30% rat burn at 3PBD) with or without DFP treatment, we tested whether DFP can rescue BI-induced upregulation of mitochondria-derived superoxide (SO) using MitoSOX staining.

Results

In WT C2C12 cells, mitophagy stimulation by DFP caused robust increase of the protein amount of BNIP3L in the mitochondrial fraction, but Parkin/PINK1 did not. KO completely abolished both basal and stimulated increase of BNIP3L. BI serum caused significant elevation of mitochondrial SO in WT myocytes ( >20 fold of SB), which was ameliorated by DFP-stimulated mitophagy augmentation (95% reduction). In KO C2C12 cells, however, DFP-induced SO reduction in BI serum was completely abolished, suggesting that DFP-mediated mitochondrial protection against BI was through augmenting mitophagy via BNIP3L pathway.

Conclusions

By using BNIP3L KO C2C12 myocytes, mitochondrial protective role of BNIP3L-mediated mitophagy against BI-induced stress was demonstrated for the first time. Previously reported cellular and organ protective functions of DFP is likely through activation of this pathway. Augmentation of mitophagy will be a promising therapeutic approach in protecting BI-induced MW and MD.
111 Optimizing an Outpatient Mhealth Intervention for Dallas with Burns: A Mixed Methods Study
Authors: Lesher Aaron , Gavrilova Yulia
Published: March 2022

Introduction

Pediatric burn injury remains one of the most common traumatic injuries in childhood. Fortunately, up to 90% of pediatric burns may be treated safely in the outpatient setting after appropriate burn triage. Patients face significant geographic disparities in access to expert burn care due to the regionalization of burn care. To aid patients and their families during acute burn recovery, a smartphone app was developed to improve patient outcomes, increase access to care, and streamline communication. The purpose of this study is to evaluate patient-derived feedback to optimize this burn app prior to subsequent efficacy testing.

Methods

The burn app was evaluated using a mixed-method approach consisting of qualitative semi-structured interviews and quantitative usability data gathered from caregivers of pediatric burn patients who utilized the app during the treatment phase of their child’s burn injury. Usability data were collected using a psychometrically validated mHealth App Usability Questionnaire (MAUQ). To analyze the interview transcriptions, we followed the Braun and Clark (2006) framework of thematic analysis. The research questions focused on caregiver perceptions of smartphone-enhanced pediatric burn care and potential app improvements, including acceptability, usability, technical preferences, and emotional perceptions.

Results

14 caregivers (93% women; M age = 36) completed the study. Overall MAUQ scores (M = 6.46; SD = .62) indicated high app usability. Ease of Use & Satisfaction (M = 6.66; SD = .42), System Information Arrangement (M = 5.93; SD = 1.07), and Usefulness (M = 6.69; SD = .61) subscales indicated an average degree of agreement above “somewhat agree” with usability statements. Furthermore, 13/14 (93%) caregivers reported a positive overall experience and agreed that the app was an acceptable method to monitor burn care. 12/14 (86%) caregivers reported that the app captured important clinical information. 53% preferred app-based burn care, 31% preferred both face-to-face and app-based care, and 15% preferred in-person only. Only 1 person preferred synchronous video-based care to asynchronous text-messaging. All study participants suggested improvements, with the most common being: (1) keeping user logged in, (2) time-stamping photos and messages, (3) consolidating text-messages and pictures, (4) adding push notifications and appointment reminders, and (5) tracking pain level.

Conclusions

Mobile health technology may be leveraged to improve outpatient burn care. The results from this study (1) demonstrate caregiver experiences using a novel mHealth platform for outpatient pediatric burn care which showed high acceptability and usability and (2) provide systematic data for app optimization.
116 Clinical Impact of Transitioning from a Burn Provider-based to Hospitalist-based Sedation Service
Authors: Khandelwal Anjay , Solomon Jeffrey D , Beaucock Beverly , Lou Richard B
Published: March 2022

Introduction

Burn patients often experience a tremendous amount of pain and anxiety during dressing changes and other procedures, frequently requiring a moderate sedation (MS) or deep sedation (DS) for successful completion. We previously reported our primarily Nurse Practitioner-based model for procedural sedation but recently transitioned to a primarily hospitalist-based sedation service. We evaluated the clinical and financial impact of this transition.

Methods

Retrospective chart review of patients undergoing MS or DS from June 2019 to June 2020 (burn provider-based [BPB]) and August 2020 to August 2021 (hospitalist-based [HB]). Data included demographics, number and types of sedation, provider type, American Society of Anesthesiology Physical Status Classification (ASA score), complications and relative value units (RVU)/anesthesia units generated. Our hospitalist completed a combined Internal Medicine-Pediatrics residency and is credentialed by the institution for procedural sedation.

Results

During the BPB sedation timeframe, 263 patients were admitted to the burn center, of which 55 patients (21%) underwent 203 sedations (average: 3.6 sedations/patient). Twenty-one (10%) were DS. The most common medications used for DS were a combination of Midazolam, Ketamine, Fentanyl, Glycopyrrolate and Ondansetron (81%); and for MS, a combination of Fentanyl and Midazolam (77.5%). Ten percent of patients had an ASA of 3 or greater.

During the HB sedation timeframe, 203 patients were admitted, of which 73 patients (36%) underwent 353 sedations for an average of 4.8 sedations/patient (74% increase). Ninety-one (26%) were DS (333% increase). Medication combinations were similar as above for DS (90%) and MS (93%). Nineteen percent of patients had an ASA of 3 or greater.

Our hospitalist performed 16% of the sedations in the BPB timeframe and 72% in the HB timeframe. In the BPB group there were 4 desaturation events (0.02%) among all sedations, compared to 8 desaturation and 1 hemodynamic change events (0.025%) in the HB group. Total work relative value units (wRVUs) and anesthesia units of service (for the DS) generated were 599.6 and 133 respectively in the BPB group compared to 1104.2 (84% increase) and 784 (489% increase) respectively in the HB group. During the BPB timeframe 40 patients were taken to the OR for dressing changes for a total of 69.3 hours, compared to zero in the HB timeframe.

Conclusions

Transitioning from a BPB to HB sedation service resulted in increased sedation numbers and percentage of patients undergoing a sedation, especially DS, as well as increased RVU generation. Sedations were performed in patients with higher ASA scores without a significant increase in adverse events. There was operating room cost and time savings. HB sedation services can be an efficacious and safe model in a burn center.
121 Acute Stress Disorder and Post-traumatic Stress Disorder in the Outpatient Burn Population
Authors: Dyamenahalli Kiran U , Carmichael Heather , Wiktor Arek J
Published: March 2022

Introduction

Early screening and intervention for acute stress disorder (ASD), diagnosed within 30 days of the inciting trauma, and post-traumatic stress disorder (PTSD), diagnosed after 30 days, are quality metrics in burn care. However, a considerable knowledge gap remains surrounding these psychological conditions in the outpatient burn setting. In this study, we assessed the effectiveness of ASD and PTSD screening at an academic burn center and identified risk factors for their development.

Methods

A retrospective cohort study of all patients treated at our ABA-verified burn center’s outpatient clinic, between July 2016 and August 2019, was undertaken. Adult patients with flame, flash, contact, or scald burns who were initially evaluated in the outpatient setting were included. ASD and PTSD were assessed using validated screening tools (ASDS and PCL-5, respectively). ASD/PTSD screening rate, screening tool appropriateness, and subsequent interventions were tracked, along with age, gender, % total body surface area (TBSA) burned, burn mechanism, operative intervention, psychiatric history, substance abuse history, and co-morbidities. Chi-square and Mann-Whitney U tests were used for univariate analysis of categorical and continuous variables, respectively.

Results

The analysis included 2494 clinic encounters and 1147 unique patients. Patients were screened for ASD or PTSD at 94.8% of encounters. Median age was 36 years (range of 18 to 94 years), 57.6% of patients were male (n=661), and median TBSA burned was 1% (range of 0.1 to 12%). Among all screens, the appropriate screening tool was applied 88.5% of the time. For all encounters, positive screening rates for ASD and PTSD were 13.2% (n=286) and 14.6% (n=48), respectively. Risk factors for positive ASD screens included a history of substance abuse (OR 1.9, p=0.03) and history of psychiatric illness (OR 2.6, p=0.002). Similarly, risk factors for positive PTSD screens included a prior positive ASD screen (OR 9.5, p=0.001), a history of substance abuse (OR 2.1, p=0.04), and a history of psychiatric illness (OR 3.3, p=0.002). Age, gender, burn mechanism, TBSA burned, and need for operative intervention did not predict positive screens. The intervention rate for positive PTSD screens by referral, counseling, or medication, was only 7.9%.

Conclusions

Demographics and burn severity do not appear to predict development of ASD or PTSD in the outpatient burn population. In contrast, a history of substance abuse or psychiatric illness warrant further attention. Despite consistent use of validated screening tools, these conditions remain under-treated in the outpatient setting, indicating a need for resource-expansion.
540 Burn-Specific Triage Guidelines in State-Based Crisis Standards of Care
Authors: Chrisco Lori , Williams Felicia , King Booker , Nizamani Rabia
Published: March 2022

Introduction

In times of crisis, medical institutions must utilize contingency plans to ensure the highest quality of patient care. When these plans are overwhelmed, crisis standards of care may be adopted, resulting in modifications in resource allocation. The current coronavirus pandemic has created tremendous strains on hospitals throughout the world, with periodic shortages in equipment, PPE, ICU beds, and personnel. These pressures have been great enough at times to result in several states implementing crisis standards of care to allow hospitals to triage patients and "do the most good possible for the largest number of people with limited resources". However, these guidelines may not account for the unique needs of burn patients, whose care is often resource intensive. We examined state-based crisis standards of care guidelines in the United States to ascertain the degree to which triage of burn patients was addressed.

Methods

Internet search engines were used to locate state-specific actionable “crisis standards of care” or “scarce resource allocation” policies available before October 1, 2021. Once identified, these guidelines were further examined to determine whether explicit information was provided to direct the triage of burn patients.

Results

Of the 50 states and the District of Columbia, only 35 states (70%) were confirmed to have official crisis standards of care policies that could be implemented by healthcare institutions during the current pandemic. Additionally, guidelines from non-government entities were identified for 4 states (Florida Bioethics Network, Ohio Hospital Association, Missouri Hospital Association, and West Virginia Hospital Association). Of the 39 plans available, only 13 (26%) provided specific information regarding triage of burn patients during implementation of crisis standards of care.

Conclusions

Crisis standards of care are heterogenous throughout the United States and have varying levels of specificity. The majority of states and the District of Columbia do not provide clear, actionable guidance on the triage of burn patients.
542 Mobile Burn Response Teams: A Scoping Review
Authors: Fuchko Danielle H , King-Shier Kathryn , Gabriel Vincent
Published: March 2022

Introduction

Advancements in the treatment of burns have reduced morbidity. However, the resources needed to deliver up-to-date care may be overwhelmed by mass casualty disasters. In 2021, the World Health Organization (WHO) recommended that countries prepare teams of deployable burn experts to assist with responding to a mass casualty disaster including burn patients. The aim of this scoping review was to identify existing literature regarding burn management mobile response team organization, describe the reported effectiveness of these teams, identify challenges in adopting the WHO recommendations and consider how the recommendations may be evolved.

Methods

We conducted a scoping review of all literature types published up to February 2021. Searches of MEDLINE, EMBASE, Scopus, and CINAHL databases were conducted to identify reports informing or reporting the use of mobile burn care specialty teams that respond to events resulting in multiple burn-injured victims, including pediatric victims and military response to civilian events.

Results

Of 5,737 identified reports, 24 publications were reviewed. Three distinct types of mobile burn response teams were identified: 1) teams organized by burn care networks; 2) government-organized medical disaster teams with burn-specific experts, and 3) the US Army Burn Flight Team. Teams have responded to events such as terrorist attacks by providing specialized burn supplies and personnel. Mobile burn response teams have demonstrated expert triage and stabilization advantages but are limited by the number of deployable specialists. A challenge in deploying a mobile team is the removal of experts from a burn centre.

Conclusions

Although the WHO recommends increasing the number of mobile burn response teams available around the world, few countries have implemented this recommendation. A hybrid model where responders on scene communicate with burn centre experts to manage triage may address these challenges.
547 Clinical Outcomes for Burned Patients with Covid-19
Authors: Walters Elliot , Shah Nikhil , Wolf Steven E
Published: March 2022

Introduction

The COVID-19 epidemic has affected all aspects of medical care including a reduction in elective procedures, however, the incidence of burns and treatment for this condition has continued undaunted. Some of these patients were also diagnosed with COVID-19 infection, but it is unclear what effect, if any the SARS-CoV 2 virus has on patients recovering from a burn injury. In this study we examined the outcomes of burned patients with a concomitant diagnosis of SARS-CoV 2 virus.

Methods

We examined a de-identified database of patient electronic medical records across 55 health care associations containing over 75 million patients. ICD 10 codes were used to identify those with thermal or chemical burns from January 1, 2020 to July 31, 2021 and those also diagnosed with Sars-CoV 2 virus infection within 1 month of injury. We found 49,501 patients suffered burns during the study time period; of these 474 patients (0.96%) also experienced a concomitant COVID-19 infection. We compared outcomes based on ICD 10 and CPT codes.

Results

We found no significant increase in mortality between groups during the study period. However, we did find a significant increase in infections, pneumonia, respiratory failure and sepsis in those with Sars-CoV infection (p< 0.05). However, there was no significant increase in ventilator management days (p >0.05) In terms of wound healing, patients with COVID-19 also experienced significantly more excision and grafting procedures and had a higher incidence of hypertrophic scarring (p< 0.05).

Conclusions

COVID-19 infection is well known to worsen respiratory outcomes, but in burned patients was also associated with an increase in other infections and poorer wound outcomes. These outcomes may emanate from a change in inflammatory status for patients with the SAR-CoV 2 virus infection. This is the first broad-based study to examine outcomes of burn victims with concomitant SARS-CoV 2 infection. Further investigation is indicated as more long-term data becomes available.
550 Considerations for Ophthalmologic Evaluation to Reduce Ocular Morbidity in Facial Burn Patients
Authors: Sweitzer Keith R , Forman Jessica , Bell Derek
Published: March 2022

Introduction

Advances in burn management have led to significant improvement in survival rates, even in patients with high total body surface area (TBSA) affected. Ocular morbidity in facial burn patients remains high, partially attributable to the life-threatening nature of these injuries. Previous studies have shown that early ophthalmologic intervention leads to better outcomes, however, specific risk factors for short and longer term ophthalmologic outcomes have not been elucidated. This study aimed to identify risk factors for short- and long-term ophthalmologic complications in facial burn patients to prioritize patients that require urgent ophthalmologic evaluation.

Methods

Retrospective review of facial burn patients presenting to an American Burn Association-verified regional burn center between June 2007 and May 2016 was conducted. Demographics, presentation, time to ophthalmologic consultation, and short- and long-term complications were recorded. Odds ratio and multivariate analyses were performed to assess for significant risk factors.

Results

A total of 1,126 facial burn patients were identified, of which 135 (12%) involved periorbital and orbital injury. Average TBSA burned was 9.68%, with an average facial surface area burned of 1.56%. The most common ocular injury was eyelid burn (65.9%). Ophthalmology was consulted for 118 (87.4%) patients. Short-term ophthalmologic complications were noted in 58 (43%) patients, most commonly chemosis (n = 34, 25.2%). Long-term complications were rare, occurring in only 7 (5.2%) patients.

Odds ratio analysis revealed that inhalation injury significantly increased the likelihood of both short- and long-term complications (OR 3.16 and OR 9.81, respectively). Active smoking increased the likelihood of long-term complications (OR 14.76). Ophthalmologic intervention, including need for consult, and use of lubricant, antibiotics, or steroids were each associated with increased risk of short-term complications.

On multivariate analysis, those with long-term complications tended to be older (p = 0.045). Those with corneal injury generally had worse outcomes, with higher likelihood of short- and long-term complications (p < 0.001, p = 0.057, respectively).

Blindness did not occur in any patient, and no long-term complications occurred in those who did not receive ophthalmologic consult. Neither TBSA nor facial SA burned was associated with the development of short- or long-term complications.

Conclusions

Providers should obtain early ophthalmologic evaluation and frequent follow-up exams for facial burn patients presenting with advanced age, active smoking status, corneal injury, or inhalation injury to reduce development of long-term complications.
563 Fire safety in homeless encampments
Authors: Rehou Sarah , Cook Greg , Doucet Nathan , Jeschke Marc G
Published: March 2022

Introduction

It is well known that people experiencing homelessness are at a greater risk for burn injury. Our burn centre saw an increase in admissions of homeless individuals during the pandemic. Typically, we partner with our hospital’s communications staff to share burn prevention public service announcements. But our usual method of broadcasting information through media like newspapers, blog posts, Facebook, or Instagram was not necessarily going to reach people sleeping rough. This report describes the development of a partnership between a burn centre, outreach workers, and people with lived experience of homelessness to improve fire safety in encampments.

Methods

Our goal was to create a Fire Safety Manual and hold Fire Safety Training Sessions. We conducted surveys that asked encampment residents questions like, “What do you use fires for?” “What fire hazards do you see at encampments?” and “How do you think fires could best be prevented?”. We used the results of this survey to guide the training manual and held workshops to engage encampment residents and incorporate feedback into the manual.

Results

The manual uses harm reductions strategies and focuses on real-life situations encountered by folks living outdoors—the manual outlines how to safely start a fire and what to do if a fire occurs. The reality is that people are trying to survive freezing winters while sleeping outside; this means that some safety standards are not possible, and the guide had to reflect that. For example, we practiced fire escape plans during training sessions and had to think about obstacles like tents with only one way out. A solution was to keep a utility knife inside and outside the tent in case one had to cut through to escape or free someone. An encampment resident suggested hiding the knives so they would not be used as weapons. We purchased fire extinguishers, fire blankets, and first aid kits that we distributed during training.

Conclusions

Education is critical to prevent burn injuries. Burn centre staff may be experts on burn prevention, but we are not experts on surviving outside. We have to be accountable to this community. This means listening, building trust, and partnering with people living outdoors. People who did training sessions were empowered to start fire brigades in their encampments. Crucial concepts are to meet people where they are and always to include people with lived experience: “Nothing about us without us.”
571 Ethnicity and Etiology in Burn Patients for the American Burn Association National Burn Repository (NBR)
Authors: Al Hosni Ahmed M , McSweeney Connor , Jain Fagun , Papp Anthony
Published: March 2022

Introduction

The purpose of this study was to analyze data from the American Burn Association National Burn Repository (NBR)

with particular focus on patient ethnicity and burn etiology. We hypothesize that burn etiology, severity and other characteristics will be significantly different between differing ethnic groups throughout the database. This information can be used to augment burn prevention strategies by targeting at risk ethnic groups.

Methods

Data on burn patients was derived from the American Burn Association National Burn Registry including all burn entries for a 10 year period (2009 to 2018) from 46 burn centers. The ethnic categories for this study were White, Black, Hispanic, Indigenous and Asian. The study also involved analysis of patient demographics, burn severity, context of injury, and hospital course.

Results

White patients were the largest group (64.0%), had the highest proportion of flame injury (53.1%) and shared the highest mortality rate with indigenous patients (3.1% compared with 2.6% for all other ethnicities). Black individuals (22.2%) had higher rates of scald burns (53.2%), the shortest average hospital stay (16.8 days) and along with indigenous patients the highest rates of assault/abuse (2.0% and 1.9% respectively). Hispanic patients (10.0%) had more scald burns (47%), the largest proportion of men (66.5%), the highest incident of work-related injuries (18.0%) and the largest average TBSA at 10.1%. Asian patients (2.7%) had the largest proportion of scald injury (63.1%) and the smallest proportion of male patients (54.5%). Indigenous patients (1.1%) had higher rates of flame burns, suffered full thickness burns at the highest rate (32.8%), had the longest average stays in hospital (21) and the ICU (15) and had the highest rates of blanks for data entry.

Conclusions

This study found multiple significant differences in burn populations when compared by ethnicity. We have found that the indigenous population suffered full thickness burns at the highest rate and have had the longest average hospital stay as well average ICU stay. We have also had the unexpected finding of higher rates of unknowns in the indigenous population which may reflect racial bias at an institutional level nationally.