bluuebunny/crossref_metadata_2025 huggingface dataset:
The Ferret as a Model for Filovirus Pathogenesis and Countermeasure Evaluation
Authors: Schiffman Zachary , Liu Guodong , Cao Wenguang , Zhu Wenjun , Emeterio Karla , Qiu Xiangguo , Banadyga Logan
Published: April 2021

The domestic ferret (Mustela putorius furo) has long been a popular animal model for evaluating viral pathogenesis and transmission as well as the efficacy of candidate countermeasures. Without question, the ferret has been most widely implemented for modeling respiratory viruses, particularly influenza viruses; however, in recent years, it has gained attention as a novel animal model for characterizing filovirus infections. Although ferrets appear resistant to infection and disease caused by Marburg and Ravn viruses, they are highly susceptible to lethal disease caused by Ebola, Sudan, Bundibugyo, and Reston viruses. Notably, unlike the immunocompetent rodent models of filovirus infection, ferrets are susceptible to lethal disease caused by wild-type viruses, and they recapitulate many aspects of human filovirus disease, including systemic virus replication, coagulation abnormalities, and a dysregulated immune response. Along with the stringency with which they reproduce Ebola disease, their relatively small size and availability make ferrets an attractive choice for countermeasure evaluation and pathogenesis modeling. Indeed, they are so far the only small animal model available for Bundibugyo virus. Nevertheless, ferrets do have their limitations, including the lack of commercially available reagents to dissect host responses and their unproven predictive value in therapeutic evaluation. Although the use of the ferret model in ebolavirus research has been consistent over the last few years, its widespread use and utility remains to be fully proven. This review provides a comprehensive overview of the ferret models of filovirus infection and perspective on their ongoing use in pathogenesis modeling and countermeasure evaluation.
Phenethyl-4-ANPP: A Marginally Active Byproduct Suggesting a Switch in Illicit Fentanyl Synthesis Routes
Authors: Vandeputte Marthe M , Krotulski Alex J , Hulpia Fabian , Van Calenbergh Serge , Stove Christophe P
Published: April 2021

Profiling of the illicit fentanyl supply is invaluable from surveillance and intelligence perspectives. An important strategy includes the study of chemical attribution signatures (e.g., trace amounts of synthesis precursors, impurities/byproducts in seized material and metabolites in biological samples). This information provides valuable insight into the employed synthesis routes at the heart of illicit fentanyl manufacture (previously mainly the so-called Janssen or Siegfried methods), allowing to track and ultimately regulate crucial precursors. This report focuses on phenethyl-4-anilino-N-phenethylpiperidine (phenethyl-4-ANPP), a formerly unknown compound that was identified for the first time in a fentanyl powder sample seized in April 2019, followed by its identification in a biological sample in December 2019. Between 2019-Q4 and 2020-Q3, phenethyl-4-ANPP was detected in 25/1,054 fentanyl cases in the USA. There are currently no reports on how this compound may have ended up in illicit drug preparations and whether its presence may have potential in vivo relevance. We propose three possible fentanyl synthesis routes that, when badly executed in a single reaction vessel, may involve the formation of phenethyl-4-ANPP. We hypothesize that the presence of the latter is the result of a shift in fentanyl synthesis routes in an attempt to circumvent restrictions on previously used precursors. Using a cell-based µ-opioid receptor recruitment assay, we show that the extent of MOR activation caused by 100 µM phenethyl-4-ANPP is comparable to that exerted by a roughly 100,000-fold lower concentration of fentanyl (0.001 µM or 0.336 ng/mL). Negligible in vitro opioid activity, combined with its low abundance in fentanyl preparations, most likely renders phenethyl-4-ANPP biologically irrelevant in vivo. However, as clandestine operations are constantly changing shape, monitoring of fentanyl attributions remains pivotal in our understanding and control of illicit fentanyl manufacture and supply.
T4 Impact of Opioid-Minimizing Pain Protocols after Burn Injury
Authors: Donthula Deepanjli , Conner Christopher R , Truong Van Thi Thanh , Green Charles , Jiang Chuantao , Wandling Michael W , Komak Spogmai , Huzar Todd F , Adams Sasha D , Freet Daniel J , Wainwright David J , Wade Charles E , Kao Lillian S , Harvin John A
Published: April 2021

Introduction

Traditionally, opioids have been the mainstay of treatment for background, breakthrough, procedural, and postoperative pain after burns. However, in addition to an impetus to reduce provider-driven opioid exposure, there is increasing evidence that opioids can worsen acute pain through induction of hyperalgesia. In 2019, we implemented a pill-based, opioid-minimizing pain protocol and protocolized moderate sedation for dressing changes. We hypothesized that these protocols would reduce inpatient opioid exposure without increasing acute pain scores.

Methods

Two groups of consecutive patients admitted to the burn service were compared: Pre (01/2018 to 07/2019) and Post (01/2020 to 06/2020) implementation of the protocols (08/2019 to 12/2019). Patient demographics, burn characteristics, and lengths of stay were abstracted from the burn registry. Opioid exposure and pain scale scores were obtained from the electronic medical record. The primary outcome was total morphine milligram equivalents (MME). Secondary outcomes included MME/day, pain domain specific MME, pain scores, and lengths of stay. Pain was estimated by creating a normalized pain score (range 0–1) from three different pain scales (Numeric Rating Scale, Behavioral Pain Scale, and Behavioral Pain Assessment Scale). Groups were compared using Wilcoxon Rank Sum and Chi Square. Treatment effect was estimated using Bayesian generalized linear models.

Results

There were no differences in demographics or burn characteristics between the Pre (n=495) and Post groups (n=174), including TBSA burn (Pre 4% [2, 10] versus Post 5% [2, 10], p=0.898). The Post group had significantly lower total MME (IRR 0.72, 95% CrI 0.57–0.93, posterior probability 99%), MME/day (IRR 0.76, 95% CrI 0.65–0.90, posterior probability 99%), and domain-specific total MME (Table). No difference in average normalized pain scores was seen. The Pre group were hospitalized longer than the Post group (5 days [2, 14] versus 4 days [1, 9], p=0.012).

Conclusions

Implementation of opioid-minimizing protocols for acute burn pain were associated with a significant reduction in inpatient opioid exposure without increased pain scores. More information is needed to understand the association with reduced hospital days.
11 Vitamin D Deficiency on Admission and the Association with Length of Stay in Patients with Thermal Injury: A Multi-center Analysis
Authors: Zavala Sarah , Pape Kate , Walroth Todd A , Reger Melissa A , Garner Katelyn , Kiracofe Brittany , Thomas Wendy L , Adams Beatrice , Hill David M
Published: April 2021

Introduction

In burn patients, vitamin D deficiency has been associated with increased incidence of sepsis. The objective of this study was to assess the impact of vitamin D deficiency in adult burn patients on hospital length of stay (LOS).

Methods

This was a multi-center retrospective study of adult patients at 7 burn centers admitted between January 1, 2016 and July 25, 2019 who had a 25-hydroxyvitamin D (25OHD) concentration drawn within the first 7 days of injury. Patients were excluded if admitted for a non-burn injury, total body surface area (TBSA) burn less than 5%, pregnant, incarcerated, or made comfort care or expired within 48 hours of admission. The primary endpoint was to compare hospital LOS between burn patients with vitamin D deficiency (defined as 25OHD < 20 ng/mL) and sufficiency (25OHD ≥ 20 ng/mL). Secondary endpoints include in-hospital mortality, ventilator-free days of the first 28, renal replacement therapy (RRT), length of ICU stay, and days requiring vasopressors. Additional data collected included demographics, Charlson Comorbidity Index, injury characteristics, form of vitamin D received (ergocalciferol or cholecalciferol) and dosing during admission, timing of vitamin D initiation, and form of nutrition provided. Dichotomous variables were compared via Chi-square test. Continuous data were compared via student t-test or Mann-Whitney U test. Univariable linear regression was utilized to identify variables associated with LOS (p < 0.05) to analyze further. Cox Proportional Hazard Model was utilized to analyze association with LOS, while censoring for death, and controlling for TBSA, age, presence of inhalation injury, and potential for a center effect.

Results

Of 1,147 patients screened, 412 were included. Fifty-seven percent were vitamin D deficient. Patients with vitamin D deficiency had longer LOS (18.0 vs 12.0 days, p < 0.001), acute kidney injury (AKI) requiring RRT (7.3 vs 1.7%, p = 0.009), more days requiring vasopressors (mean 1.24 vs 0.58 days, p = 0.008), and fewer ventilator free days of the first 28 days (mean 22.9 vs 25.1, p < 0.001). Univariable analysis identified burn center, AKI, TBSA, inhalation injury, admission concentration, days until concentration drawn, days until initiating supplementation, and dose as significantly associated with LOS. After controlling for center, TBSA, age, and inhalation injury, the best fit model included only deficiency and days until vitamin D initiation.

Conclusions

Patients with thermal injuries and vitamin D deficiency on admission have increased length of stay and worsened clinical outcomes as compared to patients with sufficient vitamin D concentrations.
13 Utilization of a Burn Sepsis Algorithm: A Five-Year Analysis
Authors: Williams Jeffrey W , Saraswat Anju , Bailey John K , Craig Christopher K , Holmes James H
Published: April 2021

Introduction

After the first 24 hours, the major cause of death in burn patients is multiple organ dysfunction/failure syndrome. It is preceded by an infection in 83% of burn patients, with reported septic mortality up to 65%. Since the early recognition and treatment of infection has been shown to decrease mortality from sepsis, we implemented a multidisciplinary algorithm designed to rapidly identify septic adult burn patients.

Methods

Adult (≥18 y) admissions between 7/1/2014 – 6/30/2019 were identified from our registry, and all initial sepsis screens were evaluated in the EMR. Patients were screened clinically at least twice daily and were considered a “positive” screen if MAP < 65 mmHg (SBP< 90 mmHg) or if 2 of the 3 occurred: Temp >102.2F; HR >120; RR >28 (or RR >10% of ventilator set rate if set rate is >24 bpm). A positive screen prompted lab work to include CBC, BMP, procalcitonin (PCT), and lactic acid (LA), per protocol. If PCT >3.0 ng/ml or LA >2.0 mmol/L, or both thrombocytopenia and hyperglycemia were present, a “Burn Code Sepsis” was initiated and included cultures, a CXR, and empiric antibiotics. A patient was then formally considered “septic” (i.e. infected) if the cultures were positive or the CXR demonstrated an infectious process.

Results

There were 1,523 admissions during the 5-year period, and 228 initial positive screens. Of the 228 patients with positive screens, 159 (70%) were infected. There was a significant difference in PCT level between patients with and without infections, while no difference was noted for LA, WBC, platelets, temperature, glucose, age, %TBSA burned, or time to triggering a positive screen between the groups (Table). Defining PCT ≥3.0 ng/mL as being positive for sepsis demonstrated a 76% PPV and a 36% NPV for PCT alone. Our initial sepsis screening algorithm had a sensitivity of 64.8% and a specificity of 40.6% over the five-year period.

Conclusions

Recognition of sepsis remains difficult in burn patients. PCT and the use of a sepsis screening algorithm may have a role in the early detection of sepsis. Further research is warranted.
49 Comparing Intravenous & Subcutaneous Insulin Regimens for Management of Hyperglycemia in Adult Burn Patients
Authors: Walroth Todd A , Luty Cole D , Brown Michelle E , Deodhar Karishma , Foster David , McIntire Allyson M , Grooms Cortni , Hartman Brett C
Published: April 2021

Introduction

Burn patients are at an increased risk of hyperglycemia due to metabolic, anabolic, and treatment-related factors. Studies in burn patients have targeted goal blood glucose (BG) values ranging from 80–140 mg/dL. Our study aimed to evaluate current management of hyperglycemia in burn patients and to develop a treatment protocol in this population.

Methods

A retrospective study of patients admitted between 10/2016 - 8/2019 was conducted. Eligible patients were at least 18 years old, admitted within 48 hours following injury, and admitted for either thermal, chemical, or electrical burn, frostbite, or inhalation injury. The primary outcome was glycemic control, defined as percent of time spent within our predefined BG goal range of 90–130 mg/dL using a time-weighted BG (TWBG) level. Insulin regimens were compared to determine the most effective modality for achieving this goal. Additional secondary outcomes included consequences of hypoglycemia, complications of poor glycemic control, length of stay, and in-hospital mortality.

Results

A total of 68 patients were evaluated, and 48 met inclusion criteria. Majority of patients were male (73%), with a mean (SD) age 60 (16) years, median (IQR) TBSA 10% (4,19), and median (IQR) baseline HbA1c 6.6% (5.6,8.2). Twenty-four (50%) patients did not have a history of diabetes. Patients spent a median (IQR) 38% (20,61) of days in goal range. Twelve patients (25%) had a TWBG level between 90–130 mg/dL. Overall, the median (IQR) TWBG level for all 48 patients was 140 mg/dL (132,160). Majority of patients were either on an insulin infusion (60%) or basal + sliding scale insulin (SSI) (51%). Patients that were on insulin infusions were controlled for a median (IQR) 75% (50,83) of days compared to patients treated using basal + SSI 20% (0,40) of days (p< 0.01). Other regimens are included in the table below. No patients were hypoglycemic (BG less than 70 mg/dL) based on TWBG.

Conclusions

The majority of patients in this study were not within goal BG range during their hospitalization. Patients were primarily managed by an insulin infusion or basal + SSI. However, the most appropriate regimen appears to be an insulin infusion or basal + bolus + SSI.
63 Risk Factors Associated with Lack of Patient Outpatient Follow Up at a Regional Burn Center
Authors: Moore Allison N , Carmichael Heather , Duffy Patrick S , Lambert Wagner Anne L , Wiktor Arek J
Published: April 2021

Introduction

Burn patients are a vulnerable population at risk for poor follow up after injury. With few burn centers throughout the country, there is often limited access to specialized care. We investigated barriers to patient compliance with recommended outpatient burn care at a single ABA-verified burn center after presentation at referring Emergency Departments (ED).

Methods

A retrospective review was performed on patients who presented at two EDs located 60–75 miles from our burn center over a two-year period. Recommendation for follow up was made by a burn surgeon at our regional burn center after telephone consultation. Medical record review was performed to determine what specific follow up occurred. Data on patient demographics, burn size/location/etiology were also recorded.

Results

Out of 135 consults from the two EDs, a total of 60 patients were recommended for outpatient follow up (vs. transfer, local management, or no follow up). Median age was 35 years [IQR 27–38] and most patients were male (n=40, 66%). Most patients had burns measuring < 1% total body surface area (TBSA) (n=43, 72%). Half scheduled a follow up appointment (n=31, 52%) and fewer came to that appointment (n=26, 43%). Median time from initial presentation to burn clinic follow up was 2 days (range 1–8 days). Of patients who did not attend recommended follow up, 24% (n=8/34) presented for additional visits to the ED or another local provider. Patients who did not follow up were more likely to be male (79% vs. 50%, p=0.03), lack insurance (27% vs. 4%, p=0.05), be homeless/institutionalized (18% vs. 0%, p=0.03) and have facial burns as compared to other body regions (32% vs. 8%, p=0.05). Patients who followed up were more likely to have scald burns versus flash/flame/contact burns (69% vs. 18%, p< 0.001) and were more likely to have been injured at home/work as opposed to outdoors/other location (100% vs. 38% p< 0.001). Age, marital status, race/ethnicity, having a primary care physician, %TBSA, and other comorbidities were not associated with follow up. Although reasons for not following up were rarely noted in the medical record, anecdotal reasons included lack of transportation (n=4), incarceration (n=3), and feeling that burns were healing (n=1).

Conclusions

Less than half of patients followed up at the regional burn center as recommended, while nearly a quarter followed up at local EDs/clinics. Barriers to follow up include patient gender, insurance, and resources (transportation).
95 Growing Up with Burn Injuries - Has the Experience Changed Over Time?
Authors: Brubaker Ruth B , Bay Curt , Kalil Emile , Chacon Daniel W , Wise Dustin K , Milem Mik , Esker Mark , Duke Desiree , Foster Kevin N
Published: April 2021

Introduction

Growing up with disfigurement and functional limitations resulting from childhood burns can be challenging. Initial stages of care involve painful surgeries/dressing changes, strenuous physical & occupational therapy, pressure garments and time away from family/school activities. Few studies have examined the voiced issues faced by youth while maturing with burns. This study’s purpose was to determine if experiences in the post-injury phase differed between currently burn-injured youth vs. young adults burned as children.

Methods

A prior study asked Child Burn Survivors (CBS -10–16 yrs.) and Young Adults (YAs -17-25yrs.) to answer the statement: “The hardest thing about being burned is…” The most common issues included: People Staring, Getting Unwanted Questions, Being Bullied, Remembering When I Was Burned, Having Additional Surgeries and My Scars. The current study asked participants to rate items on a 4-point scale from (1) Not at all to (4) Really a lot. The YAs were asked to consider issues they encountered maturing with burns.

Results

Child Survivors (CBS, n=147) mean age 13.4 years, male (n=46%) female (n=54%), and YA Survivors (YA, n = 81) male(n=39%) female (n=61%) mean age =19.1 yrs. and were predominately racial/ethnic minorities (CBS=67%; YA = 58%). No differences existed for age burned (CBS=6 yrs. vs. YA = 6.4 yrs.) hidden & visible scars (CBS=55% vs. YA=68%) and TBSA > 50% (CBS=19% vs. YA =20%). Top mean scores for CBS’s included: Remembering the Burn (2.05) & Getting Unwanted Questions (2.0). The YA group’s top mean scores included Being Bullied (2.10) & People Staring (2.0). The CBS group reported that Getting Unwanted Questions was more problematic than the YA Group (p =003). YAs shared that Being Bullied was their biggest problem vs. CVS, significantly more so (p=.01).

Conclusions

Bullying appears to be less of a problem for current child burn survivors than those previously burned. The difference may be due to a recent emphasis placed on anti-bullying in US schools. Findings highlight an ongoing need to address the psycho/social issues related to burns. Teaching interventions like the Phoenix Society’s Rehearse Your Response can help youth address unwanted questions and staring. Providing children an opportunity to process the injury event may also improve their ability to cope with burn stressors.
97 Major Psychiatric Illness and Substance Use Disorder Influence Mortality in Major Burn Injury: A Secondary Analysis of the Transfusion Requirement in Burn Care Evaluation (TRIBE) Study
Authors: Andre John A , Sen Soman , Greenhalgh David G , Palmieri Tina L , Romanowski Kathleen S
Published: April 2021

Introduction

Prior studies of burn patients with < 20% total body surface area (TBSA) burns have found that 15.4% of patients have major psychiatric illness (MPI) and 27.6% have Substance Use Disorder (SUD). In patients with small burns, SUD is associated with larger burn size and secondarily with longer length of stay while MPI is associated with longer lengths of stay while not increasing burn size. The purpose of this study was to determine whether MPI or SUD dependence affects outcomes such as mortality in patients with major burn injuries (≥20% TBSA).

Methods

A secondary analysis from the prospective, randomized, multicenter Transfusion Requirement in Burn Care Evaluation (TRIBE) study was conducted. Patients with MPI and SUD were compared with patients without these disorders. Statistical analysis with chi-square for categorical variables and student’s t-test for continuous variables was conducted. Mortality between those with and without MPI and SUD were analyzed with a multivariable regression analysis.

Results

A total of 347 patients with a mean age of 43±17 years, 274 men and 73 women, were analyzed. The mean total body surface area burn (TBSA) was 38±18%, and 23% had inhalation injury. In this study population, 29.1% had SUD, 7.5% had MPI, and 2.3% had both. There was no difference with respect to age, gender, TBSA, frailty, or assignment to the liberal or restrictive transfusion strategy based on the presence of MPI, SUD, or both. Inhalation injury was more common in patients with MPI (27%) or SUD (35%) when compared with patients without these comorbidities (18%) or those who have both (11%) (p=0.006). Patients with MPI were more likely to die of their burn injuries (27%) when compared with those with SUD (17%), both (11%), or neither (8%) (p=0.014). On multivariate analysis for mortality controlling for TBSA and inhalation injury, MPI was found to be an independent predictor of death with an odds ratio of 5 (95% confidence interval 1.7–15, p=0.003).

Conclusions

In burns >20% TBSA, both MPI and SUD influence patient’s likelihood of sustaining inhalation injury. MPI is also independently associated with mortality in the study. Further work must be done to mitigate the effects of mental illness on burn outcomes.
98 The Epidemiology of Acute Stress Disorder Among Inpatient Adult Patients with Burn Injury
Authors: Schneider Daniel M , Keyloun John W , Travis Taryn E , Johnson Laura S , Tejiram Shawn , Shupp Jeffrey W
Published: April 2021

Introduction

Burn injured patients are at high risk for developing Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD) following injury. ASD itself is a reliable predictor for the development of PTSD, which usually persists once established. Injury-related characteristics in burn patients (TBSA and anatomic location of burn) do not predict the development of psychological trauma. There is a paucity of literature examining acute psychosocial evaluations of patients with burn injury to address the need for early interventions. Behavioral health assessment and treatment in burn centers may foster improved detection and management of ASD among a variety of other mental health conditions. The goal of this study is to investigate the demographic and injury characteristics associated with new ASD diagnoses in a cohort of inpatient burn survivors.

Methods

Burn injured patients who were admitted to a regional burn center between June 2019 and June 2020 and referred for burn psychology evaluation were retrospectively reviewed. Minors, non-burn injured patients, and those with incomplete evaluations were excluded. Demographic, injury characteristic, health history, and psychologic evaluation results were collected from the medical record. ASD diagnosis was defined by criteria outlined in the PTSD Checklist for DSM-5 (PCL-5). Demographic and injury characteristic were compared between patients with and without ASD diagnoses. Statistical analysis was performed with Mann-Whitney, Chi-square, and Fisher’s Exact test as appropriate. Significance was set at a p=0.05.

Results

Fifty-two patients with median age of 49.5 (IQR, 29–62) years and median TBSA of 6 (2.8–14.4) % met inclusion criteria. Of these, 11 (21%) patients were diagnosed with ASD. Patients with ASD were more often female, (73% vs. 29%, p=0.01), younger (38.5 years vs. 46 years, p=0.05), involved in a structural fire (45.5% vs. 10%, p=0.01), and employed at the time of injury (63% vs. 14.6%, p=0.002). There were no significant differences between groups in TBSA, hospital length of stay, ICU admission, or proportion of patients requiring operative intervention. Among patients who required operative intervention, those in the ASD group underwent fewer total procedures (1 vs. 4, p=0.05).

Conclusions

Patients who developed ASD were younger, more likely female, more often involved in structural fires, and employed. Markers of injury severity such as TBSA, need for operative intervention, ICU admission and hospital length of stay were not associated with the development of ASD.
105 Implementation of a Burn Resource Team for Initial Debridement and Burn Management in a Pediatric Burn Center
Authors: Vitale Lisa C , Stankovic Curt , Cloutier Dawn , Shanti Christina M , Klein Justin D
Published: April 2021

Introduction

Each year, approximately 700 patients are treated at our verified pediatric burn center. Previously, all patients were fast tracked through the Emergency Department (ED) or directly admitted to the burn unit and received intravenous (IV) morphine and midazolam for analgesia. Although the process was efficient (goal < 120 minutes), this strategy resulted in some patients being unable to tolerate wound debridement due to inadequate sedation. As a process improvement initiative, a burn resource team, consisting of experienced nurses was created. As part of the new process, all patients are initially evaluated and treated in the ED. The Pediatric Emergency Medicine team provides procedural sedation utilizing ketamine, allowing the resource team to assess, debride, and dress the wounds. The objective was to maintain efficiency with time to debridement and dressing application, while concurrently utilizing improved patient sedation.

Methods

Door to debridement time and sedation/analgesia for first debridement was retrospectively reviewed for each group. The pre-implementation group included 148 patients from May 2018 – April 2019. The post- implementation group included 163 patients from August 2019-July 2020. Specific inclusion criteria were age < 18 years and TBSA ≤ 5%.

Results

Of the 148 patients in the pre-implementation group, 82 patients (56%) received morphine and midazolam for their analgesia. These patients had a mean TBSA of 1.5% (0.25 - 5%). 38 patients (26%) received only morphine with a mean TBSA of 1.25% (0.25 - 4%). 14 patients (9%) received hydrocodone with a mean TBSA of 0.75% (0.25 - 2.25%). The additional 14 patients (9%) received an alternate analgesic with a mean TBSA of 0.75% (0.25 - 1%). Average door to debridement time for this group was 97 minutes.

In the post implementation group, 94 of the 163 patients (58%) received ketamine sedation. These patients had a mean TBSA of 2 % (0.25 - 5%). 49 patients (30%) received Intranasal fentanyl and/or midazolam with a mean TBSA of 1% (0.25 - 4%). 13 patients (8%) received hydrocodone with a mean TBSA of 1% (0.5 - 3%). The additional 7 patients (4%) received alternate analgesics with a mean TBSA of 1 % (0.5 - 2%). Average door to debridement time for this group was 92 minutes.

Conclusions

The implementation of a burn resource team and administration of procedural sedation utilizing ketamine in the ED has improved sedation and analgesia for burn patients and marginally decreased time to debridement. There have been noticeable improvements in the consistency of the process as well as improved collaboration between the ED and burn teams.
112 Outbreak of Carbapenemase-Producing Enterobacteriaceae in a Regional Burn Centre
Authors: Rehou Sarah , Rotman Sydney , Avaness Melisa , Jeschke Marc G , Shahrokhi Shahriar
Published: April 2021

Introduction

Antimicrobial resistance is an increasing problem in hospitals worldwide, though the prevalence of carbapenemase-producing Enterobacteriaceae (CPE) in our region is low. Burn patients are among the most vulnerable to infection because of the loss of the protective skin barrier. Because of this, burn centres prioritize infection prevention and control with measures like additional precautions, enhanced environmental cleaning, dedicated facilities, and mandatory use of personal protective equipment (PPE).

Methods

This report describes a CPE outbreak in a regional burn centre. We hypothesized that contamination of in-room hand hygiene sinks with CPE was a potential source of transmission. In a period of 2.5 months, four nosocomial cases of CPE were identified, three containing the KPC gene and one VIM gene. There was more than one month between the first and second KPC case, with no overlap in patient stay or rooms.

Results

The first two cases were identified while there was no CPE patient source on the unit. CPE KPC gene was isolated in sink drains of three different rooms. In addition to the rigorous infection control practices already in place due to the unique patient population, additional outbreak control measures were implemented. The burn centre restricted admissions to complex burns or burns >10% total body surface area, in consultation with the attending surgeon. No elective admissions were permitted. To avoid CPE exposure to new patients, initial admissions were rerouted to the emergency department and, if possible, the patient was admitted to another unit. Patient cohorting was implemented through nursing team separation for CPE positive and negative patients and geographical separation of CPE positive cases to one side of the unit.

Conclusions

Despite aggressive infection control measures already in place at our burn centre, there was hospital acquired CPE colonization/infection. Given there was CPE acquisition when there was no positive patients on the unit and CPE contaminated sinks of the same enzyme were identified, it suggests that hospital sink drains can become a potential source of CPE.
123 A Novel Way of Thinking About Blast Injury Classification
Authors: Collier Zachary J , Choi Katherine J , Hulsebos Ian F , Pham Christopher H , Yenikomshian Haig A , Gillenwater Justin
Published: April 2021

Introduction

Blast injuries present unique challenges to civilian and military healthcare providers because of the complex and often severe nature of injuries spanning numerous anatomical regions, tissue types, and organ systems. Due to these factors, we devised a novel wound-focused classification system for implementation during triage and management of blast injuries to optimize outcomes and applied this system to patients treated at an ABA-certified burn center over 5 years.

Methods

A retrospective analysis of patients treated by an ABA-certified burn center for blast-related injuries from September 1, 2014 to October 31, 2019 was performed. Demographics, mechanism and distribution of injuries, interventions, and outcomes were evaluated. Injuries were classified using a wound-focused classification comprised of four zones: 1) areas closest to blast epicenter that had total or near-total tissue loss from the blast; 2) adjacent areas with thermal and chemical burns; 3) distant sites with shrapnel-related wounds; 4) injuries arising from barotrauma.

Results

We identified 64 patients who were mostly male (84%), averaging 38 ± 14 years old. Injury mechanisms included fireworks (19%), industrial accidents (16%), volatile fuels and drug labs (45%), and others including can, battery, lighter explosions (20%). All mechanisms had equivalent frequency of Zone 2 injuries with an average TBSA of 17 ± 18%. Drug-related blasts caused the highest TBSA (34 ± 23%) and the most full-thickness burns (33% vs average 23%). Fireworks had over five times (17% vs. 3%) more Zone 3 and three times (25% vs 8%) more Zone 4 injuries compared to the other mechanisms. Upper extremities were involved at twice the rate of other body regions (43% vs 19%). Patients presenting to our burn team over 24 hours after initial injury had infections in 50% of cases – a four-fold increase compared to non-delayed presentations (50% vs 13%). Overall, 45% required surgery (32% grafting, 3% flaps) but 100% of the drug-related blasts needed surgical intervention. Some patients (58%) required ICU admission with the highest rate (83%) in the drug-related group.

Conclusions

Blast injuries most often required admission for management of the Zone 2 component. Each blast mechanism resulted in distinct distributions of injury although fireworks had the greatest number of Zone 1, 3, and 4 injuries. Firework blasts were often less severe and more likely to present delayed with infectious complications. Larger blast mechanisms including drug-related lab explosions as well as industrial blasts had the highest rates of ICU admission, TBSA, full thickness depth, upper extremity involvement, and need for surgical intervention.
125 Minimal Effects of Intravenous Administration of Xenogeneic Adipose Derived Stem Cells on Organ Function in a Porcine 40%TBSA Burn Model
Authors: Heard Tiffany C , Gomez Belinda , Duarte Jamila , Dubick Michael A , Christy Robert J , Burmeister David M
Published: April 2021

Introduction

Adipose stem cells (ASCs) have shown therapeutic promise for inflammatory conditions that beget multi organ dysfunction, including burns. While ASCs have immunomodulatory properties, some studies have brought up safety concerns of increased pro-coagulant activity such as pulmonary microvascular thrombi formation after intravenous (IV) administration of ASCs. In the present study, the aims are two-fold: 1) to verify if IV administration of human ASCs promotes coagulation and 2) to determine if human ASCs affect organ function in a 40% total body surface area (TBSA) swine burn model.

Methods

Female Yorkshire swine (39.63 ± 8.26kg) were anesthetized and subjected to 40% TBSA full thickness contact burns according to a formerly established model. After recovery from anesthesia, animals were randomized to receive 15ml/kg Lactated Ringer’s Solution containing: 1- no ASCs; 2- a low dose (5x105 ASCs/kg), or 3- a high dose (5x106 ASCs/kg) over a 15-minute period as a bolus. Blood was collected at baseline (BL) and 3, 6, 12, and 24h post burn to determine the effect of ASCs on organ function and coagulation status. At 24h post-burn, animals were humanely euthanized, and kidney and liver tissue was collected for histological and Western blot analyses. Data is presented as mean ± SEM, and statistical significance was set at p< 0.05.

Results

The high dose of ASCs significantly increased the circulating number of monocytes starting at 12 hours. Two-way ANOVA revealed a significant effect of ASCs on both prothrombin times (PT) and international normalized ratio (INR) (1.03 ± 0.04, 0.93 ± 0.03, and 1.02 ± 0.04 for no, low and high ASC groups, respectively at 24 hours). There were no differences in partial thromboplastin time, fibrinogen, or d-dimer levels. Both doses of ASCs briefly exacerbated burn-induced increases in total bilirubin at 3 hours (0.062 ± 0.025mg/dL, 0.148 ± 0.060mg/dL, and 0.211 ± 0.086mg/dL in no, low, and high ASC groups, respectively). ASCs did not alter urine output; yet, there was a significant effect of ASCs on creatinine. Western blotting revealed a rise in caspase expression in the liver of animals receiving a low dose of ASCs, while there was no difference in caspase expression in kidneys.

Conclusions

We show that IV administration of xenogeneic ASCs produces minimal changes in coagulation status and renal and hepatic dysfunction. Modest changes in the extrinsic coagulation pathway were dose-dependent, while exacerbation of liver dysfunction was brief and normalized after administration of ASCs was completed. We cannot rule out that continuous infusion of ASCs would not have a cumulative effect on organ dysfunction.
133 Oxidative Stress Can Be Significantly Influenced and Reduced by Polylactide-based Membrane Dressings
Authors: Haller Herbert , Demircan Mehmet , Gurunluoglu Kubilay
Published: April 2021

Introduction

Oxidative stress is part of the physiological response to local thermal injuries and has systemic effects in more extensive burns, vascular hyperpermeability, burn edema, cellular damage, and functions of the heart, lung, liver, kidneys, muscles, and other organs. Free NO and OH radicals affect mitochondrial function, and lower energy delivery to other organelles releases thermal energy, leading to hypermetabolism. Antioxidant therapies have attempted to reduce the consequences of oxidative stress with limited effects; however, the effect of external dressings is unclear. This study aimed to investigate the positive effects of polylactide-based membranes (PLM) on oxidative stress and clinical outcomes in burns.

Methods

Herein, a prospective study assessed the correlation between oxidative stress and the severity of injuries by measuring serum malonaldehyde (MDA) and glutathione levels and the total oxidant and antioxidant capacities (TOC and TAC) among children with electrical injuries. Furthermore, a prospective randomized study evaluated the TOC and TAC, MDA, glutathione, IL-6, TNF-α, and TGF-β levels, and the ratio of telomerase positive staining in epidermal cells along the particle thickness of burns in children, when comparing polylactide dressings to Hydrofiber Ag(HFAg), autografts, and controls.

Results

Coherence between measured oxidative stress and injury severity was apparent herein. Application of PLMs significantly reduced oxidative stress in partial-thickness burns compared to HFAg. PLMs decreased the TOC (4,91 VS. 16,78 µmol/L, day 7) and increased the TAC (14,47 VS. 4,34 µmol/L, day 7). The healing duration was lesser than that of HFAg (13 VS. 21 d). Proinflammatory IL-6 levels were significantly lower in the PLM group and TNF-α values were significantly reduced from days 7 to 14. The anti-inflammatory levels of TGF-β was significantly elevated (days 3–21) in the PLM Group. Telomerase levels and the cell count were higher in healed skin in the PLM group.

Conclusions

Oxidative stress depends on injury severity and is potentially influenced by dressings. PLM mediates the regulation of oxidative stress, as evident from the TOC and TAC, and pro- and anti-inflammatory cytokines including IL-6, TNF-α, and TGF-β by PLMs might positively influence the healing duration and skin quality in burns. These results could show that oxidative stress can be significantly influenced and reduced by PLM dressings.
134 The Effect of Adipose Derived Stromal Vascular Fraction on Stasis Zone in an Experimental Burn Model on Streptozocin – Induced Diabetic Rats
Authors: Uysal Cagri A , Ozkan Burak , Al Bayati Abbas Najimaldin Muhsun , Ozgun Gonca , Akinci Kadri , Toprak Ugur , Ertas Nilgun Markal , Haberal Mehmet
Published: April 2021

Introduction

Stasis zone is the encircling area of the coagulation zone which is a critical area determining the depth and width of the necrosis in burn patients. In our study we aim to salvage the stasis zone by injecting adipose derived stromal vascular fraction (ADSVF).

Methods

Intraperitoneal Streptozotocin was administered for the induction of diabetes mellitus (DM) and the development of DM was confirmed by the measurement of blood glucose levels in the blood samples with blood glucometer weekly 48 hours after injection. Rats with blood glucose levels above 200 mg/dl were accepted as diabetic. The diabetic animals were followed for 4 weeks before the intervention.

Thermal injury was applied on dorsum of diabetic Sprague – Dawley rats (n=20) according to the previously described ‘‘comb burn’’ model. After the burn injury (30 minutes) on Sprague - Dawley rats; rat dorsum was separated into 2 equal parts consisting of 4 burn zones (3 stasis zone) on each pair. ADSVF cells harvested from inguinal fat pads of diabetic Sprague - Dawley rats (n=5) were injected on the right side while same amount of phosphate buffered saline (PBS) injected on the left side of the same animal.

One week later, average vital tissue on the statis zone was determined by macroscopy, angiography and microscopy. Vascular density, inflammatory cell density and gradient of fibrosis were determined via immunohistochemical assay.

Results

Macroscopic stasis zone tissue survivability percentage (32 ± 3.28 %, 57 ± 4.28 %), average number of vessels (10.28 ± 1.28, 19.43 ± 1.72), capillary count (15.67 ± 1.97, 25.35 ± 2.15) and vascular density (1.55 ± 0.38, 2.14 ± 0.45) were higher on ADSVF side. Fibrosis gradient (1.87 ± 0.51, 1.50 ± 0.43) and inflammatory cell density (1.33 ± 0.40, 1.20 ± 0.32) were higher on the PBS side.

Conclusions

Macroscopic and microscopic findings determined that ADSVF has a statistically significant benefit for salvaging stasis zone on acute burn injuries in DM.
139 Topical Exogenous Nutrient and Saline Supplementation to Improve Skin Graft Survival: From Lab to Operating Room
Authors: Cooper Laura E , Bohan Phillip Kemp , Christy Sean E , Chapa Javier A , Chan Rodney K , Carlsson Anders H
Published: April 2021

Introduction

Skin grafting of poorly vascularized wound beds, (e.g. exposed fascia, tendon, or bone) is often a multi-stage procedure, resulting in persistent open wounds and long-term complications such as scarring and contracture. Single-stage skin replacement could mitigate these downsides. Here we present the addition of topical nutrients and negative-pressure wound therapy (NPWT) + saline instill to improve graft take, and a case report of treatment of a non-healing wound in a single-stage procedure.

Methods

Ex vivo, STSGs (12/1000ths in) were harvested from swine (Sus scrofa domestica) post-euthanasia and transferred into wells with distilled water, PBS, Tyrode’s Buffer, high (4.5g/L) and low (2g/L) glucose DMEM, EpiLife, or William’s E (WE) media for 7 days, followed by performance of biochemical analyses and immunohistochemistry. In vivo, 20 full-thickness 5cm-diameter excisional wounds on the dorsum of two anesthetized swine were treated with dermal substitutes (DS, 0.4mm, 0.8mm, 1.2mm, or 1.6mm thickness), STSG, and NPWT with or without intermittent saline instill (3x daily, 300mL, 15-minute soak). Re-epithelialization was assessed at day 7 and 14. Lastly, a chronic 800cm2 left knee wound was treated with NPWT + instill (every 3.5 hours, 80mL, 10-minute soak, 3-day duration) over a 12/1000ths inch STSG.

Results

DMEM with high glucose (DMEM-HG) and WE produced the most lactic acid and enzymatic carbonate. Lactate dehydrogenase activity was lowest with WE. DMEM-HG had the highest glucose consumption but the most unconsumed glucose, with WE resulting in the next highest amount. Immunohistochemistry showed DMEM-HG or WE had the most dividing and least dying cells. In the porcine model, DS of 0.8mm, 1.2mm, and 1.6mm thicknesses inhibited graft take significantly (p< 0.01, p=0.02, p< 0.01, respectively) for all NPWT alone wounds. Addition of saline instill showed significant improvement in graft take (p=0.03) for 0.8mm DS wounds. 1.2mm and 1.6mm DS wounds continued to show significantly decreased graft take (p=0.03 and p=0.02, respectively). All 0.4mm DS wounds performed similar to control. Clinically, following NPWT removal on post-op day 3, almost complete STSG take was observed without exudate, pus, or malodor within the wound bed.

Conclusions

While additional studies are ongoing to determine the optimal nutrient supplementation, WE performed the best overall thus far. In vivo, 0.8mm DS created a successful model of a poorly vascularized wound bed, as NPWT + instill overcame this thickness. The novel use of NPWT + instill treatment over STSG clinically shows promise to improve graft take in the future.
141 Mild Burns Combined with Diet Induced Demyelination Does Not Affect Skeletal Muscle Function
Authors: Vardarli Emre , Bhattarai Nisha , El Ayadi Amina , Wang Y E , Jay Jayson W , Prasai Anesh , Rontoyanni Victoria G , Wolf Steven E , Song Juquan
Published: April 2021

Introduction

Severe burns result in decreased skeletal muscle mass and function. Recent evidence suggests that massive burns disrupt the motor-neural system including motor neurons to partially explain skeletal muscle dysfunction in response to burns. However, impact of demyelination on burn induced skeletal muscle dysfunction has not been investigated. The purpose of this study was to determine the impact of exaggerated demyelination on skeletal muscle dysfunction after burn.

Methods

C57BL/6 (20-25g, male, n = 26) mice were separated into 6 groups (4–5 animals per group) by diet, burn injury and timepoint (burn or sham groups with two different diets measured at two different timepoints). Mice were fed with either cuprizone diet (0.2 %) to induce severe demyelination or regular diet (18 % protein) for 5 weeks prior to injury. Burns were administered by immersing the dorsal side of the animal into ~95 °C hot water for 10 seconds (~15 % body surface area, full thickness burn). In-situ gastrocnemius function was assessed by attaching the distal tendon of the muscle to a lever arm of a force transducer and stimulating the muscle via exposed sciatic nerve while the animal was under anesthesia. In-situ gastrocnemius muscle function was evaluated 3- and 7-days after burn.

Results

Food intake was 30 % higher in cuprizone diet group compared to the regular diet group (p=0.002). However, there was no significant difference in body weight among groups (p=0.071). No significant difference was found in gastrocnemius wet weight, peak twitch tension, time to reach peak twitch tension, peak twitch half relaxation time, force-frequency relationship, maximum tetanic force, and fatigue index among groups (burn effect, diet effect, time effect, and their interactions; NS).

Conclusions

Mild burns combined with demyelination by diet had no effect on skeletal muscle function on our timepoints, and 15 % TBSA burn size was not sufficient to induce skeletal muscle dysfunction. The impact of burn induced neural damage on muscle function and performance indicates further investigation.