bluuebunny/crossref_metadata_2025 huggingface dataset:
Cocharge and Skewing Formulas for Δ-Springer Modules and the Delta Conjecture
Authors: Gillespie Maria , Griffin Sean T
Published: April 2024

We prove that $\omega \Delta ^{\prime}_{e_{k}}e_{n}|_{t=0}$, the symmetric function in the Delta Conjecture at $t=0$, is a skewing operator applied to a Hall-Littlewood polynomial, and generalize this formula to the Frobenius series of all $\Delta $-Springer modules. We use this to give an explicit Schur expansion in terms of the Lascoux-Schützenberger cocharge statistic on a new combinatorial object that we call a battery-powered tableau. Our proof is geometric, and shows that the $\Delta $-Springer varieties of Levinson, Woo, and the second author are generalized Springer fibers coming from the partial resolutions of the nilpotent cone due to Borho and MacPherson. We also give alternative combinatorial proofs of our Schur expansion for several special cases, and give conjectural skewing formulas for the $t$ and $t^{2}$ coefficients of $\omega \Delta ^{\prime}_{e_{k}}e_{n}$.
Genomic Analysis and Surveillance of Respiratory Syncytial Virus Using Wastewater-Based Epidemiology
Authors: Allen Danielle M , Reyne Marina I , Allingham Pearce , Levickas Ashley , Bell Stephen H , Lock Jonathan , Coey Jonathon D , Carson Stephen , Lee Andrew J , McSparron Cormac , Nejad Behnam Firoozi , McKenna James , Shannon Mark , Li Kathy , Curran Tanya , Broadbent Lindsay J , Downey Damian G , Power Ultan F , Groves Helen E , McKinley Jennifer M , McGrath John W , Bamford Connor G G , Gilpin Deirdre F
Published: April 2024

Respiratory syncytial virus (RSV) causes severe infections in infants, immunocompromised or elderly individuals resulting in annual epidemics of respiratory disease. Currently, limited clinical surveillance and the lack of predictable seasonal dynamics limit the public health response. Wastewater-based epidemiology (WBE) has recently been used globally as a key metric in determining prevalence of severe acute respiratory syndrome coronavirus 2 in the community, but its application to other respiratory viruses is limited. In this study, we present an integrated genomic WBE approach, applying reverse-transcription quantitative polymerase chain reaction and partial G-gene sequencing to track RSV levels and variants in the community. We report increasing detection of RSV in wastewater concomitant with increasing numbers of positive clinical cases. Analysis of wastewater-derived RSV sequences permitted identification of distinct circulating lineages within and between seasons. Altogether, our genomic WBE platform has the potential to complement ongoing global surveillance and aid the management of RSV by informing the timely deployment of pharmaceutical and nonpharmaceutical interventions.
22 A Burn Specialty Learning Experience: The Burn Center Symposium
Authors: Gleason Michael G , Shingleton Sarah , Serio-Melvin Maria L , Gonzalez Maria , Boyd Cullen , Colston Patricia , Chafin Kristine N
Published: April 2024

Introduction

The Covid-19 pandemic disrupted educational activities in our burn center and across the nation. Findings from organizational climate surveys and the American Burn Association (ABA) verification process suggested that continuing education and professional development opportunities required improvement. Clinical Nurse Specialists (CNS) collaborated with the burn center education department (BCED) to revitalize an outdated Burn Center Symposium (BCS) which was used to provide training for novice and seasoned interprofessional staff. The BCS was aligned with the ABA Burn Nurse Competency Initiative (BNCI) to provide a quarterly learning opportunity for all staff and prepare our nurses for the Certified Burn Registered Nurse (CBRN) Exam.

Methods

CNSs and the BCED cross-walked the current BCS materials to verify alignment with the BNCI domains, national accreditation, and department requirements. The team then used BNCI essential performance criteria as a framework to create lesson outlines which were used by an interdisciplinary team to update lesson plans. Additionally, burn care simulations were created to practice emergency response, respiratory therapy, and rehabilitation scenarios. Multiple choice exam and Likert surveys were created to evaluate knowledge and quality. The BCS was offered to all disciplines in the burn center; descriptive statistics were used.

Results

Two iterations of the BCS occurred in February (F) and July (J) 2023. F

results

N=19 attendees, 52% < 3 years of burn experience, a 19% increase in exam scores occurred between an average of 56% presurvey and 75% postsurvey. J

results

N=36, 90% had < 3 years of burn experience, a 15% increase in exam scores occurred between an average of 69% presurvey and 84% postsurvey. For both iterations, over 80% of the staff agreed or strongly agreed positively with course quality.

Conclusions

The results suggest that using the BNCI domains as a framework for our BCS improved knowledge of both novice and seasoned burn nurses, as well as other members of the inter-professional team.

Applicability of Research to Practice

Using the evidenced based BNCI domains as a framework for our inter-professional Burn Center Symposium improved knowledge and was the first step to prepare our nurses for the CBRN.
25 Enteral Acetaminophen Induced Hypotension: Getting It Right vs Being Right
Authors: Kesler Natalie V , Bay Curt C , Chavarria Brook , Thorstenson Elizabeth , Quan Asia N , Talanki Nisha , Van Dobbe  , Osborn Suzanne C , Islas Claudia , Hockenberry Tiffany , Richey Karen J , Foster Kevin N
Published: April 2024

Introduction

Fevers in burn injured patients is a common phenomenon and is typically managed with enteral acetaminophen (APAP) in our center. While hypotension is a known side effect of IV APAP, it has not been reported with enteral administration. However, burn nurses report episodes of hypotension in critically ill patients following APAP that are reproducible and report hesitancy to give additional doses, fearing a cause-and effect relationship. Conversely, the medical team views the relationship as temporal in nature and believes continued use of APAP an appropriate therapy to treat hyperthermia. The purpose of this study was to examine the relationship between administration of enteral APAP and hypotension in critically ill patients with thermal burns ≥ 20% total body surface area (TBSA).

Methods

This was a retrospective chart review of patients over a 5-year period. Primary outcome measures were number of patients receiving oral APAP, incidence of patients experiencing a drop in systolic blood pressure (SBP) of 20 points mmHg and/or a 15% decrease from baseline, within 3 hours, and number of qualifying hypotensive events. Descriptive statistics and Pearson correlation were calculated.

Results

A total of 203 patients suffered a burn injury of ≥ 20% TBSA during the study period. Among those 196 received enteral Tylenol, 180 (92%) experienced a hypotensive event as defined in the protocol. After consultation with a biostatistician and burn surgeon, hypotension was redefined as a SBP ≤ 100 mmHg. Using this definition 78 (40%) patients experienced at least one hypotensive event within 3 hours of APAP administration with a mean SBP of 88 mmHg, (range 58-100 mmHg). There was a positive correlation between hypotension and %TBSA (p < .001), baseline SBP (p < .000), baseline temp (p=.007), bilirubin (p < .001), mechanical ventilation (p < .001), acute adrenal insufficiency (p=.036), compartment syndrome (p=.02), and ventilator associated pneumonia (p < .005). There was no correlation between hypotension and APAP.

Conclusions

Based on our data, larger TBSA, mechanical ventilation, ventilator associated pneumonia, lower baseline SBP, increased temperature, adrenal insufficiency and compartment syndrome showed an increase in probability of a hypotensive event occurring. However, despite strong convictions from bedside nurses the study did not demonstrate a significant relationship between hypotension and enteral APAP administration. A prospective, observational study is warranted to further examine this phenomenon.

Applicability of Research to Practice

Enteral APAP can be given by bedside nursing to control hyperthermia in critically ill burn patients without hesitation or fear of causing hypotension.
33 Standardizing an Early Ambulation Protocol for Lower Extremity Grafts
Authors: O'Neil Audrey M , Rush Cassandra , Griffard Laura , Hartman Brett
Published: April 2024

Introduction

Early post-op ambulation benefits burn survivors by allowing quicker return to independent ambulation, limiting joint stiffness associated with immobilization, and preventing complications from bedrest. Burn Practice Guidelines for early ambulation were published in 2012, however significant variability in practice continues with burn centers reporting initial ambulation occurring between 0-14 days post-op, averaging on day 3 when the lower leg and foot is involved. Additionally, immobilization and weight bearing restrictions are recommended if the autograft is placed over a joint.

Methods

A retrospective review was completed of this 15 bed, adult verified burn center, from September 2020-August 2023 to identify patients who underwent split thickness skin graft (STSG) placement and/or Autologous Skin Cell Suspension (ASCS) application to their lower extremities (LE). Patients who were unable to ambulate at baseline or died during admission were excluded. Medical records were then reviewed for injury related factors, surgical interventions, post-op protocols, mobility initiation, discharge location, and wound healing using photo documentation.

Results

During the 3-year period, 149 patients with LE injury met the criteria for retrospective review. LE involvement ranged from 1-28% TBSA (Avg 6.9%). Initial homograft or dermal substitute placement was required for 56.3% (n=84) with autograft placement occurring on average post-burn day 8.5. Autograft placement included 68% Meshed (1:1-3:1) STSG (n=101), 16% Meshed STSG with ASCS (n=24), 15% ASCS (n=22), and 1% Sheet STSG (n=2). Grafts crossed joints on 119 patients including the knee (n=58), ankle (n=57), and foot (n=41). Initial ambulation occurred on average POD 1.05 using either Coban (n=68) or an Unna Boot (n=47) for compression support. Initial gait distance ranged from 2 to 1,500 ft (avg 125.4 ft). LE joint immobilization was limited to 18 patients due to post-surgical precautions and 8 patients due to active nerve blocks. No graft loss was associated with post-op ambulation. Twelve patients experienced minor graft loss, attributed to injury or surgical factors, infection, and patient comorbidities, which healed conservatively.

Conclusions

Post-op ambulation in burn patients can occur earlier than documented in previous burn research without immobilization or weight bearing restrictions. LE graft loss was not found to be associated with early post-op ambulation. Current recommendations include compression application to the lower extremity for vascular support and initiation of scar management. Immobilization can be used in cases of tendon exposure or joint compromise.

Applicability of Research to Practice

Variability in practice among burn centers regarding mobility protocols prevents adoption of early ambulation as the new standard of care. Combining rehabilitation interventions with use of compression to support STSG can allow unrestricted early ambulation.
56 Friction Burns: Defining the Rub of Road Rash
Authors: Perkins Louis , Munter Sadie , Johnston William A , Lee Jeanne , Haines Laura , Doucet Jay , Santorelli Jarrett E
Published: April 2024

Introduction

There is a paucity of literature on friction burns. The involvement of burn surgery teams and the need for surgical intervention in these cases remain relatively unexplored. This study aims to characterize friction burns resulting from motorcycle accidents, evaluate the role of specialized burn surgery teams, and assess the need for operative intervention.

Methods

The trauma registry of a Level 1 Trauma Center was queried for all admissions after motorcycle accidents between January 2018 and December 2022. Patients were included if there was an external cause of injury code for an abrasion. Abstracted data included demographics, location of abrasion, injury severity score, and presence of protective clothing. Further chart review was conducted to confirm a road rash injury, identify burn consultation, need for operating room (OR) procedure with burn service, need for skin grafting, days of burn nurse care, wound care recommendations, and burn outpatient follow-up. Potentially unnecessary burn consults were defined as consults which required no burn nursing care and where outpatient follow-up was not planned. Multivariate logistic regression was used to explore trends in burn consultation.

Results

Among the 810 patients meeting inclusion criteria, the cohort was 91.5% male, 45.6% Hispanic, with median age of 33 (IQR 26-44), and median ISS 8 (IQR 5-14). 32.7% of patients were wearing protective clothing at the time of injury. The extremities were most affected by friction burn followed by the abdomen, thorax, and face. Burn surgery was consulted in 6.9% (n=56) of cases which had a median TBSA of 3.75% (IQR 2.0-5.2%); 21.4% (n=12) of these patients underwent excision in the OR, 16.1% (n=9) required autografting, and 60.7% were referred for burn outpatient follow-up. Consults to burn were more likely in female (OR 3.67, p=0.006) and African American patients (OR 3.73, p=0.023) and those with involvement of the upper extremity, abdomen, or thorax. The median days of burn nursing care was one day (IQR 0 – 5.3 days) and 39.4% of consults made by non-burn trained trauma providers were suspected to be unnecessary.

Conclusions

We have provided a better understanding of the characteristics and treatment of friction burns, which have previously been under studied in the burn literature. Local wound care is sufficient for a vast majority of these injuries and the need for specialized burn care and operative intervention is rare.

Applicability of Research to Practice

Applicable; this study characterizes the nature of friction burns after motorcycle trauma and the role of burn surgery teams in evaluation and treatment.
57 HIV Infection Increases Risk of Sepsis and Other Complications in Burn Patients
Authors: Amador Dalton , Obias Isabel B , Segura Carolina , Ramgopal Yash , Soudah Chris K , Song Juquan , Ayadi Amina E I , Golovko Georgiy , Wolf Steven E
Published: April 2024

Introduction

Infection with human immunodeficiency virus (HIV) confers an immunocompromised status that renders patients susceptible to various pathogen-related morbidities, eventually progressing to acquired immunodeficiency syndrome (AIDS) absent antiretroviral therapy. Burn patients are also susceptible to infection due to trauma-related tissue breakdown and organ dysfunction impairing host defense and providing avenues for pathogen entry and proliferation. The purpose of this study is to explore the respective relative risks of pathogen-related complications in burn patients with HIV infection compared to those without.

Methods

This study utilized a research database that provides real-time access to de-identified medical records. Burn patients were identified using the relevant ICD-10 codes and were stratified between those who had and had not received a previous diagnosis of HIV. Subsequently risk ratios and differences between the two groups for sepsis, pneumonia, myocardial infarction, respiratory failure, acute kidney injury, and death occurring within three months of injury were generated and analyzed using the database.

Results

664,357 burn patients from 59 healthcare organizations were identified using the database. These patients were then sorted according to infection with HIV (N = 2,437) and without infection with HIV (N = 661,920) cohort. The two cohorts were balanced using (1:1) propensity score matching for age, sex, race, ethnicity, and total burn surface area (TBSA).

Burn patients with HiV infection demonstrated a greater risk of developing sepsis (risk ratio [RR], 2.800; 95% confidence interval, [1.686, 4.650]; p < 0.001), pneumonia (RR, 3.000; CI, [1.897, 4.745]; p < 0.001), myocardial infarction (RR, 2.167; CI, [1.096, 4.284]; p = 0.023), respiratory failure (RR, 1.535; CI, [1.050, 2.244]; p = 0.026), acute kidney injury (RR, 2.319; CI, [1.655, 3.249]; p < 0.001), and mortality (RR, 2.000; CI, [1.139, 3.512] p = 0.014) within three months of injury.

Conclusions

HIV infection was associated with a greater risk of sepsis, pneumonia, myocardial infarction, respiratory failure, acute kidney injury, and death in burn patients within three months of injury.

Applicability of Research to Practice

HIV infection in burn patients may be regarded as a risk factor for the various complications and morbidities analyzed in this study and guide anticipatory clinical decision-making. Future studies may explore these associations more.
68 Screen & Intervene: Mental Health Screening in the Burn Center
Authors: Alarcon Amanda R , Colarusso Linda , Strait Eli , Lee Jeanne , Smith Alan M , Minassian Arpi
Published: April 2024

Introduction

Depression, Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder (PTSD) in burn patients are common during the first year of recovery and beyond. Mental health screening of patients at all burn centers is recommended. The purpose of this study was to determine how depression or PTSD symptoms may evolve from inpatient to outpatient care in burn patients.

Methods

From March of 2022 through September of 2023, the PHQ-2 and PC-PTSD were administered to 280 outpatients via a self-report screening questionnaire. For pediatric patients < 12 years old, the primary caregiver filled out the questionnaire. A score of 2 or more on either of the screening tools resulted in further assessment by the social worker to determine appropriate next steps and provide community referrals. A subset of these patients were also screened in the inpatient setting via interview by the psychology team using the PHQ-2 and a modified PC-PTSD. The chi-square test was used to analyze the data collected.

Results

A total of 106/280 (38%) outpatients screened positive for depressive symptoms, 110/280 (39%) screened positive for ASD/PTSD symptoms, and 77/280 (27.5%) screened positive for both depressive and ASD/PTSD symptoms. Patients with facial burns were significantly more likely to have ASD/PTSD in both inpatient (14/29, p< 0.001) and outpatient (29/53, p=0.011) settings. Lower extremity burns were associated with depression as outpatients (64/148, p=0.049). Female outpatients were more likely to report depression (52/103 p=0.001) & ASD/PTSD (44/103, p=0.339) though ASD/PTSD was not statistically significant. For a number of patients, results varied between inpatient & outpatient screenings. About 35% of patients who screened negative for depression or ASD/PTSD as an inpatient then screened positive as an outpatient. Similarly, some patients screened positive for depression (23%) or ASD/PTSD (34%) as an inpatient and then screened negative as an outpatient.

Conclusions

Mental health screening of individuals in our burn center yielded a significant number of positive screens for depression and ASD/PTSD symptoms, validating the need for screening of all burn patients. Comparisons of inpatient and outpatient screens for previously hospitalized patients showed changes in depression and PTSD symptoms over time. Positive screens resulted in referrals to community and mental health resources.

Applicability of Research to Practice

Mental health screenings should be performed at multiple stages of recovery from burn injuries as manifestations of depression and ASD/PTSD may change over time.
47 Pediatric Burn Admissions: Where and When Matters
Authors: Ross Erin E , Gillenwater Justin , Yenikomshian Haig A
Published: April 2024

Introduction

There have been variable trends reported in seasonality of pediatric burns. Furthermore, risk for burn injury and mortality after burn have been associated with poorer socioeconomic status. The Childhood Opportunity Index (COI), comprised of 29 parameters of childhood well-being across the domains of Education, Health & Environment, and Social & Economic, may be a more comprehensive metric by which to assess rates of pediatric burn admission. Here, we explored trends in pediatric burn admissions seasonally, geospatially, and by COI quintile.

Methods

After IRB approval, home zip code and date of injury for all pediatric burn admissions from 2016-2022 at an urban regional burn center. Each zip code in the US is assigned to a COI quintile from Q1 (very low) to Q5 (very high) opportunity, with a roughly equal number of children living in each quintile. Population of each zip code was obtained from US Census data. We assess the number of pediatric burn admissions by month of year and zip code, and risk for pediatric burn admission for children living in very high versus very low opportunity COI quintiles.

Results

Across 470 pediatric burn admissions, there was a clear temporal trend with greater admissions in June, July and December, when children are out of school (Figure 1). Admissions for burn in children were also clustered in urban areas with higher population density (Figure 1). For all three COI sub-domains, there was an approximately five-fold increase in risk for admission for a burn for children residing in very low opportunity areas compared to children in very high opportunity areas. (Education OR 5.08 95% CI 3.54-7.27, Health & Environment OR 4.91 95% CI 3.34-7.12, Social & Economic OR 4.84 95% CI 3.41-6.86).

Conclusions

Severe pediatric burns are clustered in areas with low educational, environmental, and socioeconomic opportunity. Given the temporal association burns with the school year and strong relationship of pediatric burns with educational opportunity, child supervision is a potential target for further study.

Applicability of Research to Practice

Identifying community-level risk factors and region-specific temporal trends in pediatric burn injury can help identify highest yield areas for education and injury prevention efforts.
49 Lower Prealbumin and Albumin Levels in Unhoused Burn Patients Is a Marker for Poorer Outcomes
Authors: Donohue Sean J , Speiser Noah , Pickering Trevor A , Pham Christopher H , Gillenwater Justin , Yenikomshian Haig A
Published: April 2024

Introduction

Unhoused (UH) individuals experience burn injuries at a higher rate than the domiciled population, and have poorer outcomes following injuries. One such mechanism proposed for worsened outcomes is secondary to poor nutrition. Access to proper nutrition and food insecurity are major barriers. Malnutrition has been shown to decrease wound tensile strength, increase infection rates, and prolong healing. The purpose of this study was to understand if albumin and prealbumin could help determine outcomes in UH patients and identify at risk patients earlier in their hospital course.

Methods

A retrospective chart review was conducted of UH patients from 2019 through 2023 at a large urban safety net hospital. Data collected included admission laboratory values including albumin and prealbumin. Outcomes studied included length of stay, ICU days, ventilator days, and mortality. Data analysis included Wilcoxon rank sum test and of dichotomous variables using Pearson’s Chi-squared test, zero-truncated negative binomial model for length of stay, a negative binomial hurdle model for ICU length of stay and ventilator days, and logistic regression for mortality.

Results

385 patients met inclusion criteria in the cohort, of which 238 had albumin and 234 had prealbumin information. Each unit (g/dL) decrease in albumin was associated with 1.25 times the length of stay (95% CI = 1.01, 1.55), 1.52 times the odds of being on a ventilator (95% CI = 1.00, 2.29), and 4.46 times the odds of death (95% CI 2.13, 9.98). Each unit (mg/dL) decrease in prealbumin was associated with 1.13 times the odds of death (95% CI 1.02, 1.28). Table 1 demonstrates the relationship of admission albumin across the four patient outcomes studied.

Conclusions

Decreased admission albumin and prealbumin levels are associated with worse burn outcomes in UH patients. These nutritional biomarkers may aid in determining which UH patients are suffering from food insecurity at injury onset. Obtaining these values on admission may help burn providers target nutritional goals in their most vulnerable patients.

Applicability of Research to Practice

Albumin and Prealbumin are associated with worse burn outcomes and thus early nutritional support is of vital importance in the care of UH patients.
86 Hypothyroidism Associated with Increased Risk of Developing Contractures and Skin Disorders in Severe Burn Patients
Authors: Obias Isabel B , Amador Dalton , Segura Carolina , Ramgopal Yash , Soudah Chris K , Song Juquan , ayadi Amina E I , Golovko Georgiy , Wolf Steven E
Published: April 2024

Introduction

Patients who suffer severe burns are prone to develop various musculoskeletal and dermatological complications in the years following their injury. Hypothyroidism is classically associated with a number of muscle and skin disorders. The aim of this study is to explore the association between hypothyroidism and the emergence of these complications in severe burn patients.

Methods

Severe burn patients, defined as those with burns encompassing at least 20% total body surface area (TBSA), were identified in a research database that provides access to de-identified medical records. These patients were categorized into two groups based on whether they had previously been diagnosed with hypothyroidism. Risk ratios and risk differences of contractures, including those of the muscle, joint, and skin; atrophic disorders of the skin, including hypertrophic scarring and keloid formation; and rhabdomyolysis occurring within three years of insult between the two cohorts were generated using the database’s measure of association analysis. One-year mortality between the two groups was also analyzed.

Results

A total of 10,662 severe burn patients across 59 healthcare organizations were identified. The cohort with a previous diagnosis of hypothyroidism (N = 325) and the cohort without a previous diagnosis of hypothyroidism (N = 10,194) were balanced using (1:1) propensity score matching for age, sex, race, ethnicity, and TBSA.

The hypothyroidism cohort showed a greater risk of developing contractures (risk ratio [RR], 1.545; 95% confidence interval [CI], [1.094, 2.184]; p = 0.012) and atrophic skin disorders (RR, 1.502; CI, [1.002, 2.252]; p = 0.047) within three years of injury. There was no statistically significant difference in rhabdomyolysis between the two groups (RR, 1.000; CI, [0.422, 2.369]; p = 1). The hypothyroidism cohort showed a decreased risk of one-year mortality (RR, 0.589; CI, [.441, .789]; p < 0.001).

Conclusions

Hypothyroidism in severe burn patients is associated with an increased risk of developing contractures and atrophic disorders of the skin in the three years after their injury. It was not associated with an increased risk of rhabdomyolysis during this same timeframe but was associated with a decreased risk of mortality within one year of injury.

Applicability of Research to Practice

Hypothyroidism in severe burn patients may be regarded as a risk factor for musculoskeletal and dermatological complications pending further research. The association between hypothyroidism and lower mortality in this same population may be explored and guide the discovery of new treatments.
93 Burn Patient Perspectives on Disability Weights and the Philosophy of Disability
Authors: Won Paul , Celie Karel-Bart , Yenikomshian Haig A
Published: April 2024

Introduction

Disability-adjusted life years (DALYs) have a ubiquitous presence in academic global health, including attempts to understand the global burden of burn injuries. An important component of the DALY is the “disability weight” (DW)—a number from 0 to 1 that assigns a “badness” to the disease state in question. The numbers assigned by DWs depend on the individuals being queried, as well as the underlying philosophical model of disability that is being assumed. The present scoping review aimed to examine: first, whether DWs for burns were derived from actual burn patients (rather than from clinicians/lay public); second, whether the existing literature indicates which of the three most common philosophical models of disability aligns with burn patient experiences.

Methods

A systematic search of six databases was conducted for articles published any time until January of 2023. Inclusion criteria were studies in English, studies with human subjects, and studies investigating burn patient perspectives on disability. Study aims, methodology, and results were collected, and general themes were identified and described. The Critical Appraisal Skills Program (CASP) checklist was utilized to evaluate included studies.

Results

764 articles were returned, and 10 met criteria for in-depth review. Regarding our first aim, no studies were found that directly queried burn patient for DWs. Regarding our second aim, 4 studies contained data that could be extrapolated to burn patient perspectives on the philosophy of disability. These articles utilized semi-structured interviews and reported qualitative analysis of thematic elements such as return to work and social integration. In all studies, a recurring theme was that burn injuries are instrumentally detrimental, with modulation based on the patient’s social environment. For example, patients with manual occupations often reported a significant burden of disease and cited resumption of work as a significant factor to their social adjustment and recovery. This aligns most with a philosophical model of disability known as the welfare account.

Conclusions

This scoping review highlights a significant gap in literature. First, no studies were found that directly queried burn patients for DWs. Second, the philosophical model informing the concept of ‘disability’ in global health remains under-explored. These two themes should be prospectively studied in the burn population.

Applicability of Research to Practice

Currently employed DWs use public and health expert opinions with limited input from burn patients. This study demonstrates two significant gaps in the literature that emphasize the importance of obtaining burn patient perspectives. A solid foundation for how ‘disability’ is understood—and subsequently employed in DWs—will help to more accurately triage resources and improve patient care.
119 Single Center Central Line Associated Bloodstream Infection with Implementation of Central Venous Catheter Policy
Authors: Olehnik Scott , Libraro Kaitlyn M , Dao Sylvia H , Houng Abraham
Published: April 2024

Introduction

Central venous line (CVL) associated bloodstream infection (CLABSI) occurs at a much higher rate in burn patients. The incidence of CLABSI in burns has been reported to be two to three times that of other critical care patients. Many burn centers have their own central line policy; however, the policies are not consistent across different burn centers, and no guidelines have been published. In this study, we analyzed our institution’s CLABSI rate retrospectively after implementing a strict CVL policy.

Methods

Retrospective chart review was performed on a single institution burn center in the calendar year of 2022 and 2017-2018. The time period was chosen to account for any discrepancies due to the COVID-19 pandemic. Pediatric patients were excluded. Following data were collected: age, burn size, mechanism, length of hospital stays, CVL days, blood stream infection, and organism. CLABSI bundle information was also collected: optimal site, aseptic maintenance, timely removal, and education. This data was compared with pre-implementation data in 2017-2018. This was a quality improvement project.

Results

There were 420 patients in the study period in 2022. There were 56 patients with CVL for a total of 441 line-days. Of all the patients with CVL, there was only one CLABSI, with the incident of CLABSI being 2.27 per 1000 line days in 2022. The CLABSI standard infection ratio (SIR) was calculated to be 0.08 (SD 0.11). The decrease in CLABSI was statistically significant when compared with pre-intervention SIR of 0.77 in 2017-2018 (SD 0.169), p=0.02. The absolute incident of CLABSI went from 5 to 1, p=0.01.

Conclusions

This institution’s CVL policy consists of quantifying the line into burn CVL or non-burn CVL. Burn CVL is any line within 5cm of a burn wound. Burn CVL is changed every 3 days, and non-burn CVL is changed every 7 days. The policy allows for one over-wire CVL exchange. A new site is needed after the over-wire exchange. From the CLABSI data, this policy decreased the CLABSI SIR and absolute CLASI incidents. A multi-center implementation of the policy is needed to provide a more robust data and help combat CLABSI in the burn unit.

Applicability of Research to Practice

Directly applicable.
127 The Teen-Aged Life Impact Burn Recovery Evaluation Profile: Initial Development
Authors: Patel Khushbu F , McGwin Madeleine , Slavin Mary D , Surette Kate , Gladstone Alexandra R , Palmieri Tina L , Branski Ludwik K , Schneider Jeffrey C , Stoddard Frederick J , Murphy Michael , Kazis Lewis E , Ryan Colleen M
Published: April 2024

Introduction

Outcome measures are critical to assess interventions, establish evidence based practice guidelines, and ultimately support the needs of teenage burn survivors’ integration into the community. Only one condition- and age-specific instrument exists to monitor burn recovery. A more granular instrument with advanced technological capability (i.e., computer adaptive test (CAT)) is needed. The current study developed a preliminary conceptual framework and item pools as first steps to create a new instrument for teen burn survivors.

Methods

The International Classification of Functioning, Disability, and Health Child and Youth Version informed the conceptual framework. Initial candidate items were reviewed qualitatively through binning and winnowing. A team of experts reviewed sets of items in four rounds from March through June 2023, such that each set was reviewed twice. Experts rated each item as “keep, omit, modify, or revisit”. To identify outcomes important in assessment of recovery, focus groups of clinicians, teenagers, and parents were conducted until thematic saturation was reached. Each transcript was analyzed using deductive and inductive approaches to identify and categorize content. Findings were used to validate the framework and ensure adequate domain coverage.

Results

Initial candidate items (n=5,472) from 178 generic and burn-specific assessments previously published were grouped into two domains of the conceptual framework – activity and participation. At the end of round four, experts had modified item content for 29.8% of items. Activity item pools (n=128) included mobility, physical self-care, general tasks, experience of self, and learning and applying knowledge. Participation item pools (n=73) included major life areas, interpersonal relationships, and engagement. The recall period was set to “currently”. A five-point Likert scale format for responses was assigned based on the item measurement of agreement (n=124), difficulty (n=23), or frequency (n=54) of behavior. Eighteen participants completed the study. Clinicians mean age was 48.4 years with 90% female and 80% White; teens mean age was 13.8 years with 63% female and 75% white. Burn size ranged from 0.25 to 60% TBSA. Examples of themes included body image, self-esteem, and social relationships.

Conclusions

The preliminary item pool (n=201) was developed containing domains of activity and participation. The next step is to conduct cognitive interviews and refine item content prior to field-testing for the calibration and validation of the CAT.

Applicability of Research to Practice

Clinical and research use of the Teen-Aged12-19 LIBRE (Life Impact Burn Recovery Evaluation) will facilitate optimization of interventions, allow for more efficient allocation of resources and care for teenagers with burn injuries.
520 Are Predicted Protein Recommendation Adequate When Unable to Utilize Nitrogen Balance Testing?
Authors: Patton Lacey , Mueller Scott W , Wiktor Arek J , Gibson Cameron
Published: April 2024

Introduction

Evidence based practice on providing adequate protein for burn patients is limited. Recommendations range from 20-25% of overall caloric needs deriving from protein, or 1.5 – 4 grams (g) per kilogram (kg) of body weight. Our American Burn Association (ABA) verified burn center uses both indirect calorimetry (IC) and urine urea nitrogen balance (UUN) as a guide for patient specific caloric and protein needs. The objective of this study was to evaluate protein requirements based on 25% of predicted IC caloric needs compared to urine UUN.

Methods

This was a single center retrospective analysis at an ABA verified burn center. We included patients with 10% or greater total body surface area (TBSA) burns between 3/15/23 and 9/1/23 who completed an IC and a UUN. We excluded occurrences of invalid IC results, inaccurate protein intake records, or if a UUN occurred >7 days from the IC. Expected (Exp) protein requirements were calculated by 25% of IC resting energy expenditure multiplied by 1.3 activity factor. Observed (Obs) protein requirements were calculated by a collected 12-hour UUN + 4 grams for a ne positive nitrogen balance. Correlation of Exp vs Obs protein and matched mean difference with an assessment of estimate bias was conducted overall and as subgroups based on TBSA 10-19.9 and 20% or greater.

Results

After excluding 28 incomplete assessment pairs, 15 patients representing 34 IC and UUN assessments (8 with >1 assessment) were included. Median age and TBSA were 31 years (30, 52.5) and 20% (13.6, 33.1), respectively. Total cohort Exp and Obs protein requirements were 198 and 157 g (matched mean difference 41 g, p< 0.001), and did not correlate (Pearsons coefficient 0.06, p=0.73). In those 20% TBSA or greater, 8 patients (median TBSA 31.1%; 21.7, 59) had 23 assessments. Exp vs Obs protein requirements were 205 and 160 g (matched mean difference 45 g, p=0.001) and, poorly correlated (Pearsons coefficient 0.11, p=0.62). In those 10-19.9% TBSA, 7 patients (median TBSA 12.75%; 10.8, 14.75) had 11 assessments. Exp vs Obs protein requirements were 184.5 and 150.5 g (matched mean difference 34 g, p=0.073) and, weakly correlated (Pearsons coefficient 0.22, p=0.51).

Conclusions

Calculating protein demands based on 25% of IC caloric requirements may overestimate protein needs when compared to a measured UUN. Larger studies and continued research in nutrition support are needed to improve accuracy of estimated protein requirements.

Applicability of Research to Practice

In patients with large burns (>10% TBSA), burn centers should consider using UUN to more accurately determine patients’ adequate protein needs.
526 Methamphetamine Intoxication Predicts Worse Outcomes in Severe Frostbite Injury
Authors: Rayne Michelle M , Larson Nicholas J , Rhone Abigail , Lacey Alexandra M
Published: April 2024

Introduction

The best treatment for severe frostbite is thrombolysis with or without vasodilators, which allows reperfusion of the damaged tissue. Methamphetamine is a potent vasoconstrictor. While there is data in the burn population that methamphetamine use is associated with worse outcomes, there is no current literature on this topic in frostbite patients. It was therefore predicted that methamphetamine use predicts worse outcomes in severe frostbite injury.

Methods

This was a retrospective, single-center, observational study at a Midwest burn center. Inclusion criteria were ≥14 years of age at time of admission, severe frostbite (defined as frostbite treated with intra-arterial (IA) thrombolytics), and >24hr of IA thrombolytics as an infusion. Patients were excluded if they were lost to follow up. Over a 15 year period, 165 patients met these criteria.

The primary outcome evaluated was salvage rate, using the Hennepin Frostbite Score. To obtain this score, surgeons assessed the initial angiography images to assign a score for the amount of tissue at risk (R). A surgeon then evaluated the patient’s operative notes to assign a score for the amount of tissue amputated (A). Salvage score (S) was then calculated as follows: S = R-A. Salvage rate was calculated using this score as follows: Salvage rate = (S / R)*100%.

Results

In this sample of patients (N=165), 23.6% were positive for methamphetamine on admission (N=39). Using chi-square analysis, patients who were methamphetamine positive were statistically significantly more likely to have an amputation than those who were not (P=0.0132). All patients who had a 0% salvage rate were methamphetamine positive. This was not statistically significant.

Conclusions

We found that all patients with a 0% salvage rate were methamphetamine positive. This was not statistically significant given the low N of 11, however we find this data clinically significant and represents potential evidence of a statistical association.

This study was limited by low sample size, and thus was lacking in power to predict outcomes on a large scale. Given that this is the only study to risk stratify the relationship between methamphetamine use and salvage rate, we believe this should prompt further investigation into this relationship to evaluate for statistical significance on a larger sample size.

Applicability of Research to Practice

If this relationship is again identified in a study with a larger sample size, this would indicate a need for investigation into the most effective treatment for this population and potentially indicate a need for more aggressive intervention.
537 Burned at Sea: Transport and Critical Care of Two Sailors Injured on the Pacific Ocean
Authors: Cancio Jill M , Tadlock Matthew , Cancio Leopoldo C
Published: April 2024

Introduction

Burns have constituted 5-10% of combat casualties from recent conflicts and are projected to become even more common during future war at sea. Advances in critical care and surgery have improved postburn mortality. Nevertheless, survivors of such massive injuries require immense efforts by an interprofessional team from point of injury through the restoration of long-term function and quality of life. Here, we documented the challenges and resources required for 2 sailors who were severely burned at sea on the Pacific Ocean and who received definitive multidisciplinary care at an American Burn Association-verified Burn Center.

Methods

In July 2022, 2 sailors from a coalition nation sustained life-threatening burns during a boiler-room fire aboard a ship at sea during the RIMPAC multinational exercise on the Pacific Ocean. Multiple naval assets including the US Coast Guard, the French Navy, and the US Navy collaborated to rescue and evacuate these patients. A Burn Flight Team transported the casualties aboard US Air Force aircraft to an American Burn Association-verified Burn Center in the United States. Both sailors returned to their home country approximately 5.5 months postburn. Unless otherwise stated, data are presented as means.

Results

Patient 1 was 27 years old with an 86% TBSA burn; patient 2 was 29 years old with a 70% burn. Both sustained concomitant inhalation injury. Transfer from point of injury to definitive care took 11 days with 7 handoffs. Mean hospital length of stay (LOS) was 101 days, ICU LOS 50 days, and ventilator days 10.5. They underwent an average of 14 major surgical operations and were transfused 78 units of blood products. They received an average of 4.4 hours of direct rehabilitation per day during inpatient hospitalization, and as outpatients, they received an average of 63 rehabilitation treatment sessions.

Conclusions

The care of these 2 severely burned sailors required the coordination of naval assets from multiple countries and lengthy resource-intense definitive care at the Burn Center. These efforts took place during peacetime and were not complicated by a combat environment to include communication and air transport challenges.

Applicability of Research to Practice

Future peer and near-peer combat operations, to include war at sea, are expected to generate greater numbers of burn casualties than were seen during recent conflicts. Properly forecasting and preparing for the substantial needs of those future casualties is an essential component of readiness.
544 Unlocking Midazolam’s Potential as a Biomarker for CYP3A4 Phenoconversion in Pediatric Burn and Surgery Patients
Authors: Basas Vincent , Grimsrud Kristin N , Sherman Emma , Palmieri Tina L
Published: April 2024

Introduction

Burn patients, due to hypermetabolism, organ failure, protein binding alterations, inflammatory responses, drug interactions, and other comorbidities, are particularly susceptible to experiencing altered drug metabolism, known as phenoconversion. Phenoconversion is the phenomenon in which an individual's genetically determined metabolism phenotype shifts due to non-genetic factors, such as a normal metabolizer becoming a slow metabolizer. For example, children with sepsis have been reported to exhibit decreased CYP-mediated drug metabolism, antifungals may inhibit CYP metabolism, and certain antimicrobials and antiepileptics can induce metabolism. Research has identified specific drugs that serve as biomarkers for enzymatic rate function within individual CYP pathways. Notable examples include midazolam for CYP3A4, celecoxib for CYP2C9, and omeprazole for CYP2C19. Thus, utilizing the routine administration of preoperative midazolam may serve as a biomarker for assessing CYP3A4 function.

Methods

In our ongoing clinical pharmacogenetic studies, we collected serial serum samples from pediatric burn and surgery patients and utilized liquid chromatography mass spectrometry to measure midazolam and its primary metabolite, OH-midazolam. Preliminary analysis included 80 patient datasets (60 intravenous and 20 oral) to characterize midazolam metabolism by calculating the metabolite-to-parent ratio to identify CYP3A4 pathway induction.

Results

In our initial analysis of 80 patients, eight were identified as outliers, indicating increased metabolism. The median (min-max) ratio was 0.49 (0.01-3.84) for intravenous and 1.34 (0.2-10.50) for oral administration. The patient with the most extreme abnormal midazolam metabolism had severe epilepsy and was taking three different antiseizure medications, likely contributing to induced CYP3A4.

Conclusions

These findings underscore the importance of tailoring drug doses for patients with altered CYP3A4 function. Until further research explores the effectiveness of midazolam as a biomarker for CYP3A4 metabolism, the pursuit of precision medicine will not fulfill its promise in ensuring that all patients receive medication optimized for their dynamic metabolic rates.

Applicability of Research to Practice

This study highlights the potential of midazolam as a clinically valuable biomarker for identifying CYP3A4 phenoconversion.