bluuebunny/crossref_metadata_2025 huggingface dataset:
521 Incidence of Bone Fracture Rate Post-Burn and Trauma in Role 2 and 3 Treatment Centers
Authors: Sousse Linda E , Staudt Amanda , VanFosson Christopher
Published: April 2021

Introduction

One of the hallmarks of critical illness and trauma is that it triggers resorptive bone loss, as well as an increase in bone fractures and a reduction in bone density. Sustained markers of bone resorption, bone formation, and regulators of bone signaling pathways are linked to prolonged inflammatory activities and the prolonged deterioration of bone microstructure. The objective of this study is to evaluate the bone fracture rate of the U.S Military, non-U.S. Military, North Atlantic Treaty Organization (NATO) Military, local civilian, and Coalition Forces population in Operation Enduring Freedom and Operation Freedom’s Sentinel with burns from 2005 to 2018 using the Department of Defense Trauma Registry (DoDTR; n=28,707). Our hypothesis is that there is a direct relationship between burn injury severity and bone fracture rates.

Methods

Pearson’s correlation coefficient and scatterplots were used in this retrospective, observational study to demonstrate the correlation between total body surface area (TBSA) burn and number of fractures by anatomical location.

Results

Approximately 15,195 patients (age: 26 ± 10 years) in Role 2 and Role 3 treatment centers reported fractures. Of those patients, 351 suffered from burns with 632 anatomical fracture locations. Facial fractures were most prominent (16%), followed by foot (12%), skull (12%), tibia/fibula (11%), hand (11%), and ulna/radius (10%). There was no initial correlation between

n increasing severity of TBSA burn and count of fracture locations (ρ=-0.03, p=0.8572).

Conclusions

There was no acute correlation between burn severity and bone fracture rates; however, further analyses are required to assess chronic post-burn fracture rates.
549 Lessons Learned from Two Survivors of Greater Than 90% Total Body Surface Area Full Thickness Burn Injuries Using a Dermal Biodegradable Substitute and Autologous Skin Cell Suspension: A Case Series
Authors: Malkoc Aldin , Wong David
Published: April 2021

Introduction

Advances in burn injury knowledge, critical care, and pharmacological developments have increased survival rates among extensive burn patients. Survival now dependents not just on skin coverage, but effective control of SIRS response, metabolic derangement, fluid loss and sepsis. Novel synthetic dermal substitutes create robustness, thickness, and pliability of the skin in addition to an improved aesthetic appearance while; point-of-care autologous skin cell harvesting enhances treatment by amplifying small split-thickness skin samples to produce an autologous skin cell suspension (ASCS) to cover a larger burn area. This study reports on two survivors with greater than 90% total body surface area full-thickness burns utilizing a combined treatment of a dermal substitute along with ASCS and traditional burn management strategies.

Methods

Chart review of two patients with >90% burns and inhalation injury after being trapped in a burning vehicle following a traffic collision occurred. Most of the burns in both patients were “leathery” and consistent with full thickness, sparing only the plantar and dorsal aspect of the feet and bilateral small areas of the hip in Patient 1. Patient 2 had fourth-degree burns in some areas of the chest and flank with only the bilateral groin regions and feet spared. The patients were treated with a multi-step process which included using allograft, dermal substitute, and ASCS with split-thickness skin grafts (STSG) in place of cultured epidermal autograft to achieve coverage of >90% burns with high meshed ratio.

Results

The dermal substitute was limited to deep burns that penetrated down to fat, muscle, and/or joints. Fluid loss was well controlled by the dermal substitute during initial resuscitation. Post reconstruction, areas covered with the dermal substitute and grafted with autogenous STSG with ASCS exhibited less hypertrophy and contracture bands. The elbow and knee joints showed minimal restriction with passive motion and good skin compliance, but contractures persisted in areas where 4th degree tendon and fascia thermal injury occurred. Areas that showed signs of infection were trimmed or unroofed and allowed to drain while maintaining the remainder of the dermal substitute.

Conclusions

The use of dermal substitutes and ASCS allowed the care team to achieve SIRS control, improved fluid management, enhanced skin coverage, and reduced hospitalization stay. The process experienced in these cases shows promise for future patients with extensive burns. Both patients were able to survive and show improvement during rehabilitation.
558 Use of Forward-Looking Infrared (FLIR) Technology to Assess Burn Depth and Healing Potential: A Systematic Review and Meta-Analysis
Authors: Dang Justin , Lin Matthew E , Huang Samantha , Hulsebos Ian F , Yenikomshian Haig A , Gillenwater Justin
Published: April 2021

Introduction

Burn wound depth assessments are an important component of determining patient prognosis and making appropriate management decisions. Clinical appraisal of the burn wound by an experienced burn surgeon is standard of care but has limitations. Forward-looking Infrared (FLIR) is a new technology in burn care that can provide a non-invasive, quantitative method of evaluating burn wound depth. FLIR utilizes a specialized camera that can capture the infrared emissivity of the skin, and the resulting images can be analyzed to determine burn depth and healing potential of a burn wound. Though FLIR has great potential for burn wound assessment, its use for this has not been well documented. Thus, we have conducted a systematic review and meta-analysis of the current use of FLIR technology to assess burn depth and healing potential.

Methods

A systematic review of the literature was performed on PubMed and Google Scholar between June 2020-August 2020 using the following keywords: thermal imaging, FLIR, forward looking infrared, burn, burn depth. Meta-analysis was performed on the mean sensitivity and specificity of the ability of FLIR to predict healing potential. Inclusion criteria were articles investigating the use of FLIR for burn wound assessments in adults, pediatric patients and animal models. Reviews and non-English articles were excluded.

Results

A total of 11 articles were included in the final review. Statistically significant correlations were found between FLIR and laser doppler imaging (LDI) in 3/3 clinical studies. A case report of a single patient found that FLIR was more accurate than LDI for assessing burn depth. Three articles investigated the ability of FLIR to predict healing potential, with all three reporting statistically significant results. Significant temperature differences between burnt and unburnt skin were found in 2/2 articles. FLIR was compared to clinical assessment by burn surgeons in two articles; one article found that FLIR was more accurate for assessing burn depth, while the other article found that clinical assessment was more accurate for predicting healing potential < 21 days. Mean sensitivity and specificity of the ability of FLIR to determine healing potential < 15 days was 44.5 and 98.8 respectively. Mean sensitivity and specificity of the ability of FLIR to determine healing potential < 21 days was 44.0 and 77.4 respectively.

Conclusions

FLIR is an accurate, simple, and cost-effective method of burn wound assessment. FLIR has been demonstrated to have significant correlations with other methods of assessing burns such as LDI and can be utilized to accurately assess burn depth and healing potential.
574 A Nurse Educational Program to Promote Spiritual Care Delivery: Development and Pilot Testing
Authors: Henderson Tammy L , Bender Miriam , Joe Victor C , Thompson Patrick E , Thomas Mini
Published: April 2021

Introduction

Spiritual Care (SC) is crucial for the holistic care of patients. Findings from a needs assessment conducted on an 8-bed burn Intensive Care Unit (ICU) (n=34, 88% response rate) revealed 90.3% of nurses believed SC was important for the overall care of their patient, but only 13% felt confident to provide the religious care. Of the respondents, 77% had come across a time when they were unable to obtain SC for their patients. The survey revealed 39% were interested in obtaining education to enhance their provision of holistic care. Based on this data, we developed and pilot tested an innovative SC educational course to examine feasibility, learning, and preliminary outcomes.

Methods

The IRB-approved study involved a two-hour evidence-informed class developed by a burn nurse and chaplain. The course was offered on a voluntary basis for all nurses in the critical care division (5 units overall). The class consisted of PowerPoint presentation, case studies and practice utilizing spiritual care assessment tools. Data was collected before and after the class at one- and two-months post class completion.

Results

Participants (n=12) were mostly female (82%), Bachelors prepared (82%), affiliated as Christian (73%) and had not had spiritual education in the past (73%). Nurses also agreed the spiritual assessment tools were useful and they were confident using them. Mean total score for Nurses’ Spiritual Care Practice increased 14% over time. Practices with the largest increases included reading/offering spiritual writings to patients (67/57%) and documentation of meeting spiritual needs (40%). The Spiritual Care Perspective scale increased 7% overall with changes in the beliefs of SC being a significant part of Advanced Nursing Practice (ANP) (10% increase), the domain of APN includes SC (15% increase) and nurses should assist a patient in using his/her spiritual resources to cope with illness (9% increase). At 2-months post training, participants felt comfortable (4.25/5.0 and confident (4.0/5.0) providing SC.

Conclusions

SC is an essential element of holistic nursing practice that has become even more relevant in this pandemic year. Our 2-hour educational class was considered well organized, provided relevant education and tools for use, and increased nurses confidence, comfort, and documentation of providing SC to their patients.
584 Increase in Cancellation Rates with Follow-Up Telemedicine Visits in a Burn Clinic Setting
Authors: Wiley Nicholas A , Chrisco Lori , King Booker
Published: April 2021

Introduction

Telemedicine is a resource to help limit in-person contacts, which has become increasingly utilized during the Coronavirus pandemic. In the last year, most health care systems have attempted to limit in-person visits in order to help decrease Coronavirus transmission. A retrospective analysis was conducted to determine if the use of telemedicine resulted in an increase in cancellation rates. The data on cancellation rates of a burn clinic using telemedicine was collected for a seven-month period in 2020. The increased rate of cancellations for telemedicine visits compared to in-person visits was found to be statistically significant.

Methods

A retrospective analysis of patient cancellation rates for 2,463 burn outpatient visits seen in a burn clinic associated with a large tertiary referral burn center was performed covering the time period between April 1st and August 30th of 2020. Cancellations of initial visits for new or recently discharged patients were not included as telemedicine visits were only offered for established burn outpatients. Rescheduling rates for both groups were calculated to assess a potential impact on cancellations. Telemedicine visits consisted of patient encounters conducted by phone or by live video chat. Statistical significance was determined using chi-square test with an accepted p < 0.05.

Results

The study included 2,463 scheduled outpatient visits comprising 511 telemedicine visits and 1,952 in-person visits. A cancellation rate of 47% occurred for telemedicine visits and a cancellation rate of 40% was observed with in-person visits. Patient visits conducted using telemedicine were associated with a higher cancellation rate (p=0.013). The reschedule rate for telemedicine visits was 22% while in-person visits had a rate of 25% showing no significant association (p = 0.45).

Conclusions

Telemedicine follow-up visits were found to have an increased rate of cancellations compared to in-person visits. Rates of rescheduling showed no significant difference between groups.
594 Racial and Ethnic Disparities in Burn Patient Outcomes: A Review of the Literature
Authors: Peters Jasmine N , Bello Mariel S , Spera Leigh J , Gillenwater Justin , Yenikomshian Haig A
Published: April 2021

Introduction

Racial and ethnic disparities in outcomes for surgical trauma populations has been an expanding field in recent years. Despite this, disparities in prevention, treatment, and recovery outcomes for burn patients of racial and ethnic minority backgrounds have not been well-studied. Our study aims to review the literature regarding risk factors and burn outcomes among racial and ethnic minority populations to develop culturally-tailored burn care for minority burn patients.

Methods

A systematic review of literature utilizing PubMed was conducted for articles published between 2000–2020. Searches were used to identify articles that crossed the burn term (burn patient OR burn recovery OR burn survivor OR burn care) and a race/ethnicity and insurance status-related term (race/ethnicity OR African-American OR Asian OR Hispanic OR Latino OR Native American OR Mixed race OR 2 or more races OR socioeconomic status OR insurance status). Inclusion criteria were English studies in the U.S. that discussed disparities in burn injury outcomes or burn injury risk factors associated with race/ethnicity.

Results

1,031 papers were populated, and 38 articles were reviewed. 26 met inclusion criteria (17 for adult patients, 9 for pediatric patients). All but 4 of the included papers were written in the last 10 years. 17 of the 26 articles describe differences in outcomes or risk factors for Black Americans, 8 discuss Latinx, 5 discuss Native Americans, 3 discuss Asian Americans, and 1 referred to “Non-White” minorities, collectively. Majority of studies showed that racial and ethnic minorities (vs. Whites) exhibited poorer burn injury outcomes such as higher mortality rates, greater scar complications, and longer duration for length of stay.

Conclusions

Few studies exist on outcomes for minority burn populations. Interestingly, most have been published in the last 10 years, which may indicate a trend in increased awareness. There is also a discrepancy in which minorities are included in each study with the least amount of data collected on Asian, Latinx, and Native American communities. More research with a larger base of minority populations will help further investigate this problem and develop better culturally-appropriate burn treatment.
595 The COVID Effect: Exploring the Impact of Coronavirus on an Academic Burn Center
Authors: Moore Meredith , David Parizh , Dale Elizabeth , Slater Julia C
Published: April 2021

Introduction

Globally, medical centers have faced unprecedented times with the onset of the Novel Coronavirus pandemic. Emergency departments (ED) and burn units have had to adapt to uncertainty and new challenges. At our institution, we had to alter our daily burn practice, physically moving our burn unit to our surgical intensive care unit to accommodate staff cohorting. While some hospitals have seen patient surges, most have endured dramatic decreases in productivity. A UK burn unit documented lower ED presentations and reduced referrals from other centers, with 50% fewer patients admitted to their burns ward (Farroha). In Israel, a 66% decrease in adult burn patients was noted (Kruchevska et al.). We sought to identify the impact of COVID-19 on burn injury epidemiology in our burn unit based in a large, urban, academic medical center.

Methods

We conducted a retrospective review of our burn database for ED visits and admissions related to burn injuries between March 1st and June 30th in the years 2017, 2018, 2019, and 2020. We looked at the age and sex of patient, type of visit, length of stay (LOS), the mechanism of injury, the setting in which injury occurred, and the details of the injury. We compare annual trends, with emphasis on comparison of 2020 to previous years.

Results

From admissions and ED data records, 215 patient encounters were reviewed. We saw a yearly rise in total burn patients seen in the ED or admitted to our burn unit 2017–2020 (39, 43, 63, and 70 respectively) with the highest volume of patients in 2020. Mean patient age ranged from 45 (2020) to 51 (2017). More males were burned in all years (male:female ratio 3.9 in 2017, 2.1 in 2018, 2.5 in 2019, 1.9 in 2020). Median LOS in 2020 was 2.5 days, consistent with 2017–2019 values (2, 3, 3, respectively). Between 2017 and 2019, 10%, 2%, and 8% respectively of patients evaluated were treated on an outpatient basis, while in 2020, 20% were outpatient. Rates of flash, scald, flame, chemical, electrical, and contact burns were stable over the period. Of those patients who were admitted, 1.8% sustained work-related burns in 2020 versus 8.9% over 2017–2019. In 2020, 23% of burns were cooking related versus 18% over the prior 3 years.

Conclusions

Despite documented decreased burn admissions in some units, our unit saw an increase in burn injuries presenting for evaluation in the first 3 months of the COVID-19 pandemic as compared to the analogous period in the three years prior. Burns were less often tied to work-related incidents and more frequently related to cooking injuries. Even with more patients treated and released from the ED, inpatient admission numbers were maintained. These findings support the importance of protecting our staffing and burn unit resources in a pandemic setting in order to appropriately treat regional patients and an increase in home-based injuries.
601 Burn Injuries Associated with At-home Hair Braiding
Authors: Shakir Afaaf , Teele Megan , O’Connor Annemarie , Gottlieb Lawrence J , Vrouwe Sebastian Q
Published: April 2021

Introduction

Hair braiding that incorporates synthetic extensions has increased in popularity across all age groups. During the styling process, the ends of the braid are commonly dipped in hot water. As a result of this practice, an increasing number of patients have presented to our Burn Center after containers of recently boiled water are accidentally tipped over and spilled onto patients. Here, we report on patient demographics, outcomes, and our experience managing this injury pattern.

Methods

A retrospective chart review was performed of all patients who sustained burn injuries associated with at-home hair braiding presenting to an ABA-verified Burn Center between January 1, 2006 and July 31, 2020. Data on patient demographics, injury characteristics, wound management and, burn outcomes was collected.

Results

A total of 41 patients presented over the study period with burn injuries related to at-home hair braiding. The frequency of this type of burn increased over time, with 54% of injuries occurring in the last three years (2018–2020). The mean patient age was 7.5 years (range 0.7 – 32 years). Demographically, the vast majority of patients were under 18 years of age (90%), female (95%), and African American (98%). Seventy-three percent of injuries occurred at the patient’s home and 88% of incidents involved another person in the hair braiding process. The mean total body surface area of burn was 5% (range 1–20%). The most commonly involved areas were the back (54%), thigh/leg (37%), neck (24%), shoulder (24%), and arm/forearm (22%). Ninety percent were entirely partial thickness injuries with 10% of patients suffering some degree of full thickness injury. Ninety percent of patients required inpatient admission, and 36% of patients required at least one operative procedure. For those managed as inpatients, the average length of stay was 5.4 days (range 1–30 days). Three patients were reported to experience complications with one developing respiratory failure and two with delayed wound healing.

Conclusions

Hair braiding, with the use of scalding water to seal and set the ends of braids, can lead to significant accidental burn injuries. At our institution, these injuries occur predominantly in young African-American females. These burns can result in acute hospitalization and the need for surgical intervention. This is the largest series of this injury type to date with trends towards increasing frequency in the most recent time period.
602 Concomitant Pediatric Burns and Craniomaxillofacial Trauma: A Pediatric Burn Center’s Experience over 20 Years
Authors: Xun Helen , Mafla Laura M , Caffrey Julie , Hultman Charles S
Published: April 2021

Introduction

Recent progress in pediatric burn care has reduced the mortality rate by 48.1% (Armstrong, 2020). Although it is well understood that mortality increases with increased number of systems involved, prior studies have not documented the effect of concomitant pediatric burn and craniomaxillofacial (CMF) trauma in pediatric patients. This retrospective cohort study is the first known to characterize presentation, management, and long-term outcomes of concomitant burns with CMF trauma in pediatric patients.

Methods

We performed a retrospective cohort study of all pediatrics patients who presented at a tertiary care center between the years 1990 to 2010 with CMF fractures and burns. Patient charts were reviewed for demographics, mechanism of injury, burn characteristics (TBSA %, location, and degree), imaging and interventions, involvement of child protective services, and long-term outcome. Data was analyzed using two-tailed Student’s t tests and chi square analysis.

Results

Of the 2,966 pediatric CMF trauma patients (64.0% boys; average age 7 ±4.7 years) that were identified, a total of 10 (0.34%) patients were identified to have concomitant burn injuries. Patients with concomitant burn and CMF injuries were less likely to have sustained blunt injuries (P < 0.0001) and had longer hospital lengths of stay (13 □ 18.6 vs 4 □ 6.2 days, P < 0.0001). Approximately 60% of CMF fractures were upper-third injuries. The CMF fractures of all 10 cases (100%) were managed non-operatively. 40% were due to child abuse, 40% due to motor vehicle collisions, and 20% due to house fires. Of the four patients who presented due to child abuse, CMF trauma was incidentally found on imaging. One (13 months, female) child-abuse case was found to have 32% TBSA 2nd and 3rd degree burns to bilateral lower extremities after being submerged in hot bathwater and had concomitant orbit/skull fractures. Two other child abuse cases presented with hand burns and concomitant nasal/skull fractures. All four child abuse patients presented in a delayed fashion.

Conclusions

Concomitant burns and CMF trauma is rare injury pattern in pediatric populations and is associated with longer hospital lengths of stay. Child abuse and motor vehicle accidents caused 80% of the cases.
608 Perceived Burnout among Burn Surgeons: Results from a Survey of American Burn Association Members
Authors: Kinslow Kyle , Elkbuli Adel
Published: April 2021

Introduction

Burnout is a significant and increasingly recognized issue. We aimed to investigate burn surgeons’ (BSurg) perceptions regarding burnout, contributing factors, and implications to better identity possible targeted interventions.

Methods

42-question anonymous online survey was distributed by the ABA to BSurg members. Respondents included BSurgs in university or non-university hospital settings.

Results

Experience of burnout was reported among 89.8% of university and 84.6% of non-university hospital affiliated respondents. After adjusting for confounders, university BSurgs exhibited higher risk of perceived burnout compared to non-university settings (aOR 1.081, 95%CI:0.237,4.937). Women BSurgs were at 5 times higher risk of reporting burnout compared to men (aOR 5.048, 95%CI:0.488,52.255). BSurgs aged 40–44 had twice the risk of reporting burnout as ≥50 (aOR 1.985, 95%CI:0.018,216.308). Practicing for 21–30 years had 12 times higher risk of reporting burnout than practicing >30 (aOR 12.264, 95% CI:0.611,246.041). Those working < 50 hours/week reported burnout more frequently than those who work ≥80 hours/week (aOR 2.469, 95% CI:0.80,76.662).

Conclusions

Overall reports of burnout were high amongst burn surgeon respondents. Those with 21–30 years of clinical practice were at significantly higher risk of reporting burnout despite believing that their colleagues’ burnout was more frequent than their own. Interventions addressing perceived burnout in younger burn surgeons may be limited by lack of participation due to fear of repercussions from administration or peers. Future administration-led burnout initiatives should acknowledge the differences between burn surgeon groups and offer resources unique to the individual physician’s needs for burnout prevention to be successful.
609 Combined Physical, Occupational, and Psychotherapies in the Holistic Care of the Burn
Authors: Dae Melanie K , Smith Tyler M , Goetz Stephen , Schnake Erin , Lambert Wagner Anne L
Published: April 2021

Introduction

Burn patients often experience pain and fear of the recovery process, negatively impacting their engagement in necessary treatments for maximal functional outcomes. Patients routinely exhibit aversions toward physical and occupational therapies (PT and OT). As a result, therapists have been tasked with managing the patient’s psychological reactions while simultaneously providing rehabilitation. We developed a program for our psychologist to co-treat patients with burn physical and occupational therapists to directly address the painful or feared aspects of burn recovery. These multidisciplinary visits offer in-vivo interventions for managing patient distress and allows therapists the ability to focus solely on their specialized interventions.

Methods

This program has been active for 12 months and was created during therapy to aid a patient with high distress during PT and OT. Therapists now work with psychology to co-treat improving patient engagement in rehabilitative interventions. During co-treatment, the patients are able to engage in PT and OT more effectively and achieve short-term goals. The burn center psychologist and therapists have developed an interventional method to explore potential generalization of co-treatment effectiveness. Patients are identified based on high need for psychological support during therapy sessions. Each patient case is reviewed and discussed to develop individualized treatment plans and establish goals. Through qualitative review of each co-treatment visit, common barriers have been identified as well as strategies to improve engagement and compliance.

Results

The common barriers encountered had a high association with a history of traumatic experiences and avoidant coping/low distress tolerance. The most effective co-treatment interventions included: collaboratively setting patient goals with PT, OT and psychology; scheduling patient therapy with burn psychology in advance; teaching distress tolerance skills to manage anticipatory and in-vivo distress related to rehabilitation.

Conclusions

Treating the emotional aspects of burn recovery during moments of acute distress is integral for holistic patient care. This multidisciplinary approach offers patients increased involvement through collaboratively tailored treatment planning and improved ability to tolerate distressing aspects of recovery. Additionally, therapists were taught various approaches to improve patient engagement and adherence.
614 Addressing Increasing Mental Health Needs in Burn Patient Population: Dedicated Burn Center Psychologist
Authors: Dae Melanie K , Smith Tyler M , Lambert Wagner Anne L
Published: April 2021

Introduction

During the past four years, mental health coverage at our burn center has evolved and become more robust. The emotional aspects of burn recovery are well documented; patients often present with co-morbid psychological conditions and develop psychological conditions as a result of the traumatic experience of their injury and subsequent hospitalization. To address this need, our burn center created a burn psychology fellowship and hired a dedicated full-time attending psychologist.

Methods

The burn center medical director has advocated for increased mental health support for several years. Mental health support was initially provided by the Psychiatry Consultation-Liaison team, and primarily focused on medication management for patients with severe mental illness. Recognizing the need for additional support, the burn center hired a part-time psychologist. After two years of part-time dedicated psychology coverage, a full-time position was approved. Through quantitative data review over the past several years, the number of patients with psychiatric diagnoses and the number of patients connected to mental health treatment during their hospitalization was analyzed.

Results

The overall patient census at the burn center has increased over the past several years (n=319 FY2016 vs n=506 FY2020). Burn patients with mental health diagnoses has increased along with and beyond the overall patient census growth; 34% (n=173) of patients admitted had a documented psych diagnosis in FY2020 compared to just 21% (n=68) of patients admitted in FY2016.

Conclusions

Integrating full-time psychology coverage dedicated to the burn center has allowed our patients to be evaluated and treated sooner, which has resulted in shortened time to psychotherapy and psychiatric medication management, and improved discharge planning to include outpatient mental health treatment. A full-time burn psychologist has improved holistic patient care of our burn patient population to positively aid in their overall recovery process.
620 Outbreak of Carbapenem-Polymyxin-Quat-Resistant Acinetobacter Baumannii Associated with Mafenide Acetate shortages: An Interdisciplinary Approach to Eradication
Authors: Fleming Irma D , Tang Carla , Lewis Giavonni M
Published: April 2021

Introduction

In the wake of Hurricane Maria, many US hospitals experienced massive drug shortages requiring substitution with alternative therapies. Our regional center experienced an increased incidence of Carbapenem-Polymyxin-Quat-Resistant Acinetobacter baumannii(CPQRA) infections, compared to a previous year of no infections. Here we describe a successful interdisciplinary approach to its eradication.

Methods

We conducted a retrospective review of CPQRA outbreaks for November and December 2018 in the burn ICU. De-identified data was collected and analyzed. In collaboration with the state’s department of health and epidemiology section, whole-genome sequencing was carried out on bacterial isolates. In addition, we instituted adenosine triphosphate (ATP) monitoring on all surfaces, a process of rapidly measuring actively growing microorganisms.

Results

Resistant Acinetobacter was isolated from five ICU patients, two of whom died with CPQRA bacteremia, producing a case-fatality rate of 40%. The two cases that died both suffered traumatic injuries with multiple fractures in addition to an average TBSA of 58%. Non-fatal cases suffered no other traumatic injuries and had an average TBSA of 51%.During this period, genitourinary irrigant (neomycin-Polymyxin B) and polymyxin ointment were the primary topical agents for wound care. Whole genome sequencing revealed a qacEdelta1 positive strain and identified the primary source as a patient that returned from a long-term care facility carrying the converted A. Baumannii infection. ATP testing also showed increased levels in patient rooms and surgical suite.

Conclusions

As a result of these findings, we achieved eradication by developing new and reinforcing traditional practices of infection control. This included UV light therapy to all ICU rooms and surgical suite, oversight of environmental services procedures, rigorous enforcement of hospital infection control procedures, auditing hand hygiene, increased efforts in antibiotic stewardship and discontinuing Polymyxin containing topicals. By January 2019 there were no new cases of CPQRA in the ICU. This study shows that the resistance and rapid spread of CPQRA can be controlled with the cooperation of hospital staff, environmental services, infection control, pharmacy, and the state’s department of health. With the coordinated efforts of all parties, we were able to successfully eradicate a virulent and fatal resistant A. baumannii strain.
664 “Minimally Invasive” Skin Grafting with Enzymatic Debridement and Autologous Skin Cell Spray
Authors: Kahn Steven , Hink Ashley , Karsch Jordan , Halicki Elizabeth , Hickerson William L , Holmes James H , Carter Jeffrey E
Published: April 2021

Introduction

Minimally invasive surgery is increasingly becoming standard of care across numerous subspecialties. However, burn surgery has lagged behind; as the mainstay of reconstruction still involves wound excision with a knife, a commensurately sized skin graft, and a painful donor site. In recent years, several new technologies have the potential to be used synergistically to perform “minimally invasive” skin grafts. Enzymatic debridement with bromelain and autologous skin cell spray (ASCS) have independently been shown to reduce the need for split-thickness skin graft (STSG) and decrease the donor site size when grafting is performed. Bromelain is more likely to preserve healthy dermis and ASCS allows an 80:1 expansion. Due to constraints regarding the temporal course of these products only being available via studies before one was FDA approved, these two therapies have not been utilized together in the US until recently. A paucity of literature regarding their use in combination currently exists.

Methods

This study is a single site review of patients treated the continued access study protocol for bromelain-based enzymatic debridement and with ASCS per the FDA-approved instructions for use. Enzymatic debridement was performed over a 4-hour period with appropriate analgesia. Deep partial-thickness burns with residual dermis were treated with ASCS after enzymatic debridement and superficial dermabrasion. Wounds were dressed with a small pore non-adherent film and layered gauze. Full-thickness burn injuries were treated with conventional STSG.

Results

Two patients were treated over a 2 week period. One was a 51 yr old male with 17% TBSA superficial and deep partial thickness flame burns, of which 11% were deemed deep enough to warrant treatment with enzymatic debridement. 15% TBSA was treated with ASCS including the arms, back, and posterior neck with a 24 sq cm donor site. Wound closure was noted post-operative day 7 with complete re-epithelialization. The second patient was a 21-year-old male with several comorbidities impairing wound healing (diabetes [HgbA1c of 9.9], scurvy, and zinc deficiency. He had deep-partial and full-thickness burns to bilateral feet. The dorsum of the right foot was reconstructed with ASCS only and a 6 sq cm donor site, and the left foot was treated with a 3:1 meshed STSG and ASCS overspray with 100% take.

Conclusions

Enzymatic debridement and ASCS can be utilized to treat deep partial-thickness burns with a “minimally invasive” reconstruction. The donor sites in both patients were much smaller than had they been treated with a conventional meshed STSG. Further study is needed to determine which subsets of patients and burn wound characteristics are optimal for this combination of technologies. More data regarding outcomes such as length of stay, costs, and scar formation compared to standard of care is also warranted.
670 Delayed Enzymatic Debridement of Burn Wounds using the Proteolytic Gel SN514
Authors: Jockheck-Clark Angela R , Stone Randolph , Holik Michelle , Schaffer Lucy , Natesan Shanmugasundaram , Roche Eric , Christy Robert J
Published: April 2021

Introduction

Thermal burns account for 5–10% of casualties sustained in present-day conflicts and are expected to be one of the most common wounds to occur in future conflicts. In prolonged field care (PFC) situations, medical evacuation could be delayed for days. During this time, burn wounds can become infected, detrimentally impact neighboring tissue, and cause systemic immune responses. Therefore, it is essential to test and evaluate non-surgical debridement agents that could be implemented prior to reaching a Role 3 military treatment facility. This work details how the proprietary proteolytic gel SN514 impacts burn debridement when applied within a PFC-like timeline. SN514 contains an enzyme formulation that is thermostable, easy to apply, and selectively degrades non-viable tissue in vitro and in vivo.

Methods

Deep-partial thickness contact burns were created using an established porcine model and covered with gauze or an antimicrobial incise drape. Four days later, the burns were treated with one of five treatments: 0.2% SN514, 0.8% SN514, a vehicle control, gauze, or an antimicrobial silver dressing. Treatments were re-applied every 24 hours for 72 to 96 hours. The effects of the treatment regiments were compared histologically. Biopsies were also taken to monitor bacterial contamination levels.

Results

Burns treated with SN514 were partially debrided and visually distinct from those treated with gauze, the silver dressing, or the vehicle control. Preliminary analyses suggest that SN514-treated burns that had been covered with “dry” gauze had a much lower debridement efficiency than those treated with the incise drape. This suggests that SN514 debridement efficiency may depend on the presence of a moist eschar. Preliminary analyses also suggest that there was little difference in burn wound bacterial counts among the five treatment groups.

Conclusions

SN514 is able to debride burns that experienced delayed treatment, without any evidence of harm to the surrounding tissue or evidence of exacerbating the original burn injury. SN514-treated wounds displayed little to no blood loss and did not increase burn wound infection levels compared to wounds treated with gauze or an antimicrobial silver dressing.
674 Machine Learning and Automation in Burn Care: A Systematic Review
Authors: Huang Samantha , Dang Justin , Sheckter Clifford C , Yenikomshian Haig A , Gillenwater Justin
Published: April 2021

Introduction

Current methods of burn evaluation and treatment are subjective and dependent on surgeon experience, with high rates of inter-rater variability leading to inaccurate diagnoses and treatment. Machine learning (ML) and automated methods are being used to develop more objective and accurate methods for burn diagnosis and triage. Defined as a subfield of artificial intelligence that applies algorithms capable of knowledge acquisition, machine learning draws patterns from data, which it can then apply to clinically relevant tasks. This technology has the potential to improve burn management by quantitating diagnoses, improving diagnostic accuracy, and increasing access to burn care. The aim of this systematic review is to summarize the literature regarding machine learning and automated methods for burn wound evaluation and treatment.

Methods

A systematic review of articles available on PubMed and MEDLINE (OVID) was performed. Keywords used in the search process included burns, machine learning, deep learning, burn classification technology, and mobile applications. Reviews, case reports, and opinion papers were excluded. Data were extracted on study design, study objectives, study models, devices used to capture data, machine learning, or automated software used, expertise level and number of evaluators, and ML accuracy of burn wound evaluation.

Results

The search identified 592 unique titles. After screening, 35 relevant articles were identified for systematic review. Nine studies used machine learning and automated software to estimate percent total body surface area (%TBSA) burned, 4 calculated fluid requirements, 18 estimated burn depth, 5 estimated need for surgery, 6 predicted mortality, and 2 evaluated scarring in burn patients. Devices used to estimate %TBSA burned showed an accuracy comparable to or better than traditional methods. Burn depth estimation sensitivities resulted in unweighted means >81%, which increased to >83% with equal weighting applied. Mortality prediction sensitivity had an unweighted mean of 96.75%, which increased to 99.35% with equal weighting.

Conclusions

Machine learning and automated technology are promising tools that provide objective and accurate measures of evaluating burn wounds. Existing methods address the key steps in burn care management; however, existing data reporting on their robustness remain in the early stages. Further resources should be dedicated to leveraging this technology to improve outcomes in burn care.
Dangerous Liaisons: The Story of Special Economic Zones, International Investment Agreements, and Investor–State Dispute Settlement
Authors: Chaisse Julien
Published: April 2021

This article focuses on the interaction and relationship between Special Economic Zones (SEZs) as facets of unilateral economic law, international investment law, and the investor–state dispute settlement (ISDS) system in a four-fold manner. It initially explains the role of international investment agreements in protecting foreign investments in these zones. Then, it classifies the public or private nature of such zones and goes on to examine related claims through past case law, to determine how modern SEZs must be created to reduce host State liability. Whilst doing so, it provides important suggestions to improve the domestic and international success of SEZs by reducing costs associated with it. In this manner, this article endeavours to highlight the need for a balance in public policy between the rights of host States and foreign investors to ensure that SEZs continue to attract significant amounts of foreign investment. It also stresses on understanding transnational foreign investment rules and the implication of the previously concluded investor–ISDS proceedings so that host States can ensure better regulation of foreign direct investment in these areas.
Pharmacological intervention in oxidative stress as a therapeutic target in neurological disorders
Authors: Sharma Sudhanshu , Advani Dia , Das Ankita , Malhotra Nishtha , Khosla Akanksha , Arora Vanshika , Jha Ankita , Yadav Megha , Ambasta Rashmi K , Kumar Pravir
Published: April 2021

Objectives

Oxidative stress is a major cellular burden that triggers reactive oxygen species (ROS) and antioxidants that modulate signalling mechanisms. Byproducts generated from this process govern the brain pathology and functions in various neurological diseases. As oxidative stress remains the key therapeutic target in neurological disease, it is necessary to explore the multiple routes that can significantly repair the damage caused due to ROS and consequently, neurodegenerative disorders (NDDs). Nicotinamide adenine dinucleotide phosphate (NADPH) oxidase is the critical player of oxidative stress that can also be used as a therapeutic target to combat NDDs.

Key findings

Several antioxidants signalling pathways are found to be associated with oxidative stress and show a protective effect against stressors by increasing the release of various cytoprotective enzymes and also exert anti-inflammatory response against this oxidative damage. These pathways along with antioxidants and reactive species can be the defined targets to eliminate or reduce the harmful effects of neurological diseases.

Herein, we discussed the underlying mechanism and crucial role of antioxidants in therapeutics together with natural compounds as a pharmacological tool to combat the cellular deformities cascades caused due to oxidative stress
Strangulated Amyand’s hernia: management during the COVID-19 pandemic
Authors: Afzal Zeeshan , O’Neill Robert
Published: April 2021

Amyand’s hernia, presence of the appendix within an inguinal hernial sac, is a rare condition. We report a case of a 68-year-old woman who presented during the COVID-19 pandemic with an acute right groin pain due to a tender incarcerated inguinal hernia. Cross-sectional imaging confirmed an Amyand’s hernia. She proceeded to open appendectomy via the inguinal canal and primary suture repair of her inguinal hernia. Patient was discharged the following day. Surgical management of Amyand’s hernia varies depending on the resources, clinical findings and personal experience. In our opinion and experience, open hernia reduction, appendectomy and primary tissue repair repairs the most effective and appropriate approach especially during the COVID-19 pandemic.
Xylem versus phloem in secondary growth: a balancing act mediated by gibberellins
Authors: Carlsbecker Annelie , Augstein Frauke
Published: April 2021

This article comments on:

Ben-Targem M, Ripper D, Bayer M, Ragni L. 2021. Auxin and gibberellin signaling cross-talk promotes hypocotyl xylem expansion and cambium homeostasis. Journal of Experimental Botany 72, 3647–3660.
Viscous and Knudsen gas flow through dry porous cometary analogue material
Authors: Schweighart M , Macher W , Kargl G , Gundlach B , Capelo H L
Published: April 2021

According to current theories of the formation of stellar systems, comets belong to the oldest and most pristine class of bodies to be found around a star. When approaching the Sun, the nucleus shows increasing activity and a pressure increase inside the material causes sublimated and trapped gas molecules to stream away from their regions of origin towards the surface. The present work studies two essential mechanisms of gas transport through a porous layer, namely the Darcy and the Knudsen flow. Gas flow measurements are performed in the laboratory with several analogue materials, which are mimicking dry cometary surface properties. In this first series of measurements, the aim was to separate gas transport properties from internal sources like local sublimation or release of trapped gases. Therefore, only dry granular materials were used and maintaining a low temperature environment was unnecessary. The gas permeability and the Knudsen diffusion coefficient of the sample materials are obtained, thereby representing the relative importance of the respective flow mechanism. The experiments performed with air at a stable room temperature show that the grain size distribution and the packing density of the sample play a major role for the permeability of the sample. The larger the grains, the bigger the permeability and the Knudsen diffusion coefficient. From the latter, we estimated effective pore diameters. Finally, we explain how these parameters can be adapted to obtain the gas flow properties of the investigated analogue materials under the conditions to be expected on the comet.