bluuebunny/crossref_metadata_2025 huggingface dataset:
26 Opioid Prescription in Burns: A Large Database Analysis from 1990 to 2021
Authors: Villarreal Elvia L , Wolf Steven E , Golovko George , Wermine Kendall , Gotewal Sunny , Huang Lyndon G , Corona Kassandra K , Bagby Shelby P , Keys Phillip H , Joglar Alejandro A , De La Tejera Giovanna , Chokshi Shivan N , Song Juquan , El Ayadi Amina
Published: March 2022

Introduction

The use of opioids in the medical field has contributed to the growing opioid epidemic. Nonetheless, opioids remain imperative in the treatment for pain management in burns. While some studies have addressed the use of opioids in surgery, a comprehensive analysis of the pattern of opioids use in burns has not been investigated. This study aims to identify trends of opioid use and investigate the risk of opioid related disorders in burn patients.

Methods

Data was obtained from TriNetX, a national research database that provides medical records of de-identified patients. The study population includes patients that were prescribed an opioid, ICD-10 code CN101, on or after any instance of burn between January 1st, 1990 and September 19th, 2021. Patient population was further stratified by the decade in which patients received opioids for pain following burn injury: 1990-1999, 2000-2009, 2010-2019, and 2020-September 19th, 2021. Five outcomes were investigated: opioid related disorders, opioid dependence, opioid abuse, intentional self-harm, and mental and behavioral disorders due to psychoactive substance use. Cohorts were matched for age at index, sex, and race. Statistical analysis used risk ratios with a 95% confidence interval, and p< 0.05 was considered significant.

Results

We identified 8,421 patients that were prescribed an opioid between 1990-1999, 30,846 patients from 2000-2009, 169,991 patients from 2010-2019, and 30,966 patients from 2020-present. When compared to the 2000s cohorts, the 1990s patients had a 47% decrease in risk of opioid related disorders, with a 53% decrease in risk of opioid dependence, 45% decrease in risk in opioid abuse, 11% decrease in risk of mental and behavioral disorders due to psychoactive substance use, and 63% reduced risk of intentional self-harm.

Comparison of the 2000-2009 to 2010-2019 cohorts showed increased risk of opioid related disorders (RR= 1.912), opioid dependence (RR=1.569), opioid abuse (RR=1.677), mental and behavioral disorders (RR =1.733), and intentional self-harm (RR=2.027). When compared to 2020-present, the 2010-2019 patient cohort had 10 times the risk of developing opioid-related disorders, with 3 times the risk for opioid dependence and behavioral disorders, and 5 times the risk for opioid abuse and intentional self-harm.

Conclusions

The risk of opioid related disorders in the 1990s was lower compared to the 2000s. Since 2000, the risk of opioid related disorders has significantly increased. Recognizing the risks of opioid prescriptions in burn patients is imperative when addressing the role of physicians in controlling the constantly growing opioid epidemic.
37 Procedural Pain Management in Burn Patients (Phase II) - A Quality Improvement Project
Authors: Pedroza Albert , Fleishhacker Zack , Galet Colette , Wibbenmeyer Lucy
Published: March 2022

Introduction

This quality improvement project (QI) focused on reducing procedural pain. Phase I of this project demonstrated a need to improve our patients' and nurses’ satisfaction with pain control management during hydrotherapy. In this phase (Phase II), we educated the nursing staff on 1) appropriate dosing and timing of opioid administration (Oral and IV) and 2) need for more frequent midazolam administration before hydrotherapy. We also assessed the safety and potential benefits of ketamine for procedural pain control.

Methods

Patients undergoing wound cleaning procedures were surveyed for up to three hydrotherapy encounters. Nurses were educated on procedural pain control prior to this current phase. A convenience sample of patients underwent ketamine administration. Ketamine was administered per protocol starting at 0.3 or 0.4 mg/kg with intermittent boluses of 0.25 mg/kg as needed. Demographics, opioid (oral morphine equivalents, OME), midazolam, and ketamine doses and time of administration, and adverse events were collected. Patient pain scores (1-10) before and after hydrotherapy and patient and nurse satisfaction scores (1-10) after hydrotherapy were collected. Paired t-tests and one-way ANOVA were performed. P < 0.05 was considered significant.

Results

During Phase II, 9 patients and 19 encounters were analyzed; of which ketamine was administered for 10 events. Compared to Phase I (28 Patients and 50 encounters), education of the nursing staff resulted in a significant improvement in giving midazolam prior to hydrotherapy (78.9% vs. 10%; p < 0.001) and opioid administration (27.4 OME vs. 20.2 OME, p = 0.043). Timing of opioid administration did not improve when compared to Phase I (Outside the window of efficacy: 42.1% vs. 43.8%, p = 0.903). Both patient (8.7 ± 2.4 vs. 7.7 ± 2.1; p = 0.011) and nurse (8.2 ± 2.1 vs. 7.3 ± 1.9; p = 0.021) satisfaction scores regarding pain control improved. None of the patients who received ketamine experienced adverse effects. Notably, the use of ketamine improved nurse satisfaction scores with patient pain control (9.2 ± 0.8 vs. 7.1 ± 2.6; p = 0.035). While patients on ketamine were more satisfied with pain control, significance was not reached (9.4 ± 1.1 vs. 7.9 ± 3.2; p = 0.315).

Conclusions

Our data demonstrate that nurse education regarding medication administration was effective, but further education is needed to improve the timing of opioid administration. Ketamine offers additional benefits that deserve additional study.
44 Endothelial Monolayers Treated with Burn Patient Plasma Exhibit Differential Gene Expression Linked to Cytoskeletal Rearrangement
Authors: Kelly Edward J , Keyloun John W , Carney Bonnie C , Moffatt Lauren T , Shupp Jeffrey W
Published: March 2022

Introduction

Burn shock is one of the most serious and complex complications suffered by patients following thermal injury. Endothelial dysfunction may play a role in the pathogenesis of burn shock. However, the mechanisms underlying the contribution to pathophysiology are still largely unknown. Previous studies have shown a connection between the rearrangement of cytoskeletal elements leading to increased vascular permeability. The aim of this study was to examine the differential expression of genes involved in cytoskeletal arrangement in endothelial cell monolayers treated with plasma from burn patients.

Methods

Human umbilical vein endothelial cells (HUVECs) were seeded into transwell plates to form confluent monolayers. Plasma was collected from burn patients 4 hours post-admission. HUVEC cells were exposed to 10% multi-donor pooled healthy human plasma (HHP) or burn patient plasma. Monolayers were subsequently incubated with FIT-C Dextran (40,000 kD) for 2 hours. Monolayer permeability was measured with indices calculated by normalizing values to blank wells (transwell inserts) and HHP-treated monolayer FIT-C diffusion. RNA was isolated from these same cells that had increased monolayer permeability and PCR analysis was carried out using an 84 gene array of human cytoskeletal regulators (Qiagen). A Ct value of 35 was used to indicate expression and a fold change of 1.5 to indicate differential expression in the control vs. injured groups.

Results

Four burn patient plasma samples were utilized to create injuries. Patients were mostly male (75%) with a mean age of 50±20 years and mean %TBSA burn of 37±34%. Differential gene expression in burn vs. HHP was compared. Ten genes showed significant upregulation (ARHGDIB, AURKA, AURKB, CCNB2, CIT, IQGAP2, VASP, SSH2, MYLK and DIAPH1). Four genes showed significant downregulation in (FSCN2, ARHGAP6, CYFIP2, CCNA1). Monolayer permeability indices showed statistically significant increases when compared to controls ranging from 3-13.33% (p < .05).

Conclusions

The interplay of burn shock and endothelial dysfunction remains a complex process of which much is unknown. However, RNA analyses of burn patient plasma reveals involvement of multiple cytoskeletal regulators. Furthermore, all these samples show a concurrent increase in permeability indices when compared to controls, further strengthening the association between cytoskeletal rearrangement and endotheliopathy. Future research to better understand the specifics of these pathways could help aid in the development of more targeted treatments of endotheliopathy and burn shock. Cytoskeletal rearrangement may be an interesting target for future work to understand this mechanistic interplay.
46 Bardoxolone-methyl Microparticles Ameliorate Immune Dysfunction Following Burn and Inhalation Injury Through the NRF2/KEAP1 Axis
Authors: Seim Roland F , Maile Rob , Hall Hannah R , Wallet Shannon , King Booker
Published: March 2022

Introduction

Severe burn injury leads to many systemic stresses that can seriously impact multiple systems throughout the body. These stresses are further exacerbated if there is a combined burn and inhalation injury, which leads to increased morbidity and mortality for many patients. Combined burn and inhalation injury causes an intense systemic inflammatory response and activation of the innate immune system which can lead to inflammatory complications, such as systemic inflammatory response syndrome and multiple organ failure. Nuclear Factor-Erythroid-2-Related Factor (NRF2) is a transcription factor that acts to downregulate overt damaging pro-inflammatory and oxidative responses and maintain immune homeostasis. This transcription factor remains bound to Kelch-like ECH-associated protein 1 (KEAP1) in the cytoplasm. Under oxidative stress, NRF2 dissociates from KEAP1 and translocates to the nucleus where it facilitates the transcription of anti-inflammatory and antioxidant genes. We hypothesized that NRF2 is a key regulator after burn and inhalation injury, and activation of NRF2 can limit the severity of burn and inhalation injury.

Methods

To test this, we have developed a mouse model of combined cutaneous burn and woodsmoke inhalation injury. After burn and inhalation injury, we found that NRF2-/- knockout mice have higher mortality compared to wild-type (WT) mice and suffer from increased vascular permeability and lung edema, suggesting that this transcription factor is important for controlling morbidity and mortality. In WT mice, NRF2 is activated following burn and inhalation injury, however, based on immunohistochemical staining, it is not sufficiently induced following this insult since it remains in the cytoplasm and is unable to transcribe anti-inflammatory genes. Therefore, we treated WT mice with an intraperitoneal injection of bardoxolone-methyl microparticles, a NRF2 activator that separates KEAP1 from NRF2 in the cytoplasm, immediately after burn and inhalation injury in WT mice

Results

We observed significant decreases in mortality as well as reduced concentrations of certain pro-inflammatory cytokines in the blood and bronchoalveolar-lavage fluid of these mice. In the lungs of these mice, there was an upregulation in numerous pathways involved in the management of inflammation and immune response compared to mice that did not receive bardoxolone-methyl microparticles.

Conclusions

In conclusion, treatment with bardoxolone-methyl microparticles immediately after burn and inhalation injury might be effective for reducing the severity of the inflammatory response and limiting inflammatory complications.
47 Successful Prevention of Secondary Burn Progressions Using Topical Tacrolimus and Infliximab Hydrogel
Authors: Kalmar Christopher L , White-Dzuro Colin G , Pollins Alonda , Burns Brady , Assi Patrick , Thomas Harrison , Jackson Kianna , Perdikis Galen , Bellan Lleon , Thayer Wesley
Published: March 2022

Introduction

The pathophysiology of partial- to full-thickness burn wound conversion remains poorly understood. Recent studies have demonstrated that an altered inflammatory response may play be implicated in this secondary conversion to deeper wounds. Therefore, reduction in early inflammation may decrease burn severity and morbidity.

Specifically, TNF-ɑ has been shown to detrimentally affect the healing process after injury through a variety of mechanisms. We hypothesized that microcapillary alginate hydrogel loaded with immunosuppressive medications applied to partial-thickness burns would reduce inflammation and prevent further progression to full-thickness burns.

The purpose of this study was to determine whether topical application of infliximab or tacrolimus could decrease burn wound depth.

Methods

Assembly of the microfluidic hydrogels was achieved by embedding microfibers within a hydrogel scaffold composed of an alginate blend. The treatment cohorts received either (1) infliximab loaded hydrogel or (2) tacrolimus skin ointment covered by hydrogel. The control cohort only received an occlusive dressing.

There were 12 young (2-4 months) and 12 old ( >16 months) mice, which were separated into treatment and control cohorts. All mice were anesthetized and given partial thickness burns by a validated scalding protocol. Mice were euthanized on post-burn day 3, and skin samples were taken. Burn depth was evaluated using Vimentin immunostaining.

Results

In young mice, infliximab hydrogel (p=.002) and tacrolimus hydrogel (p=.002) significantly decreased burn depth compared to controls. In old mice, infliximab hydrogel (p=.005) and tacrolimus hydrogel (p< .001) significantly decreased burn depth compared to controls.

In young mice, infliximab and tacrolimus were similarly efficacious (p > .05). In old mice, tacrolimus significantly decreased burn depth compared to infliximab (p=.002).

In controls, old mice had deeper burn wound progression than young mice (p< .001). Similarly, in those treated with infliximab, old mice had deeper burn wound progression than young mice (p=.002). Interestingly, tacrolimus was able to decrease burn wound depth in old mice such that their burn wound thickness was similar to young mice (p >.05).

Conclusions

Application of a novel microcapillary alginate hydrogel infused with infliximab or topical tacrolimus reduced partial- to full-thickness burn wound conversion in mice. Application of immunosuppressive dressings may be a promising avenue for further clinical investigation to reduce morbidity and mortality associated with burn injuries.
48 Metformin Rescues the Aging-induced Failure of Post-burn White Adipose Browning
Authors: Barayan Dalia , Knuth Carly M , Jeschke Marc G
Published: March 2022

Introduction

Severe burns are responsible for an estimated 300,000 deaths per year worldwide. While modern burn care has markedly improved survival for pediatric and adult patients, this is sadly not the case for one population: the elderly. Despite being the fastest-growing demographic in North America, burn patients over the age of 60 years have the highest mortality and morbidity rates. Recent evidence suggests that progressive aging induces several structural and functional alterations which impair the capacity of older trauma patients to adequately respond to stress. Indeed, it was discovered that reduced survival in elderly burn patients is associated with the failure to initiate the browning of white adipose tissue (WAT) —a hallmark of the systemic response to injury commonly observed in adults. Interestingly, the widely used hypoglycemic drug metformin has been found to protect against aging-induced metabolic decline in various pathological conditions. Thus, we investigated the anti-aging effects of metformin on the metabolic deterioration of post-burn WAT responses in elderly patients and mice after injury.

Methods

Human WAT was obtained from elderly patients admitted to our burn center. Elderly (75-week) mice received a full-thickness scald burn and/or daily intraperitoneal injections of metformin (100 mg/kg) for 7 days. The inguinal WAT was harvested for histological analyses. Mitochondrial respiration was measured via Seahorse XF96. Gene and protein expression was assessed via RT-PCR and western blot, respectively.

Results

Post-burn metformin treatment restores the thermogenic activation of WAT in elderly patients and mice, reflected by the increased expression of key browning markers, UCP-1 and PGC-1α (p< 0.05). This was accompanied by higher mitochondrial respiration, improved lipolysis (p< 0.05) and increased fat wasting (p< 0.01) relative to control counterparts. The anti-aging effects of metformin appeared to be mediated by AMPK, which consequently increased [NAD+] (p< 0.01), thereby promoting activation of the longevity-specific enzyme Sirt-1 (p< 0.05).

Conclusions

Here, we show that post-burn metformin treatment effectively rejuvenates adaptive metabolic responses in elderly WAT by targeting key longevity pathways which rescue the age-dependent loss of being back to youthful levels. Our findings support the potential of anti-aging modalities to improve care and outcomes in elderly burned patients.
54 Cost of Dakin’s Solution vs. Mafenide Soaks in Acute Burn Care
Authors: Hirsch Jason , DeHoff Deanna , Hollowed Kathleen , Halicki Elizabeth , Condeni Melanie S , Hink Ashley , Ozhathil Deepak , Kahn Steven A
Published: March 2022

Introduction

The cost of health care in the United States is extremely high, with burn care being no exception to this rule. A 2016 study found that burn care costs are twice as much as the cost of non-burn related inpatient admissions, necessitating the need for cost savings. As one such measure, the authors no longer routinely use mafenide solution for burn care, and now use 0.0125% Dakin’s as a default topical irrigant, due to lower cost and less cytotoxicity. The aim of this analysis is to investigate the cost savings from using Dakin’s Solution (0.125%, 0.25%, and 0.50% strengths) versus the theoretical cost of using an equivalent amount of 5% mafenide.

Methods

This study was a retrospective review that characterized a single cohort of burn patients treated with Dakin’s solution in the pre and post operative setting. Graft loss was recorded and defined as >25% loss. As a default, 0.125% Dakin’s was used, and concentration was potentially escalated based on attending judgement of wound characteristics. We qualitatively compared length of stay (LOS) index to expected for length of stay index using 1.1 hospital days per %TBSA and using 2019 NBR statistics of 3 days per %TBSA for survivors. Using costs of $37.29 (0.0125%), $40.69 (0.25%), and $38.11 (0.5%) per liter of Dakin’s versus $165.05 per liter for 5% mafenide, we looked at potential savings per patient and for the entire cohort. Average cost, median cost, and total cost of both Dakin’s solution and Mafenide were calculated. Mann Whitney Test was used to compare costs of Dakin’s versus theoretical cost of mafenide.

Results

The total number of cases analyzed was 39 (n=39). The median burn size was 4% TBSA (IQR:1,6) and the median LOS was 3 days (IQR:2,8) The average cost for Dakins per patient was $721.61 versus $3172.98 had mafenide been used, p< 0.001. When all of the Dakins use was amalgamated, this represents a potential cost savings of $2451.37 per patient and $95603.43 for the entire cohort. LOS index was 0.68 with the conservative measure and 0.25 using 2019 NBR data. Only 2 patients had unplanned readmissions within 30 days. None of the patients suffered graft loss.

Conclusions

Use of Dakin’s solution as an alternative to mafenide results in a significant potential cost savings compared to 5% mafenide. The patients treated with Dakins in this study spent less time in the hospital than expected compared to national averages. In addition to lower strength Dakin’s dilutions being well established as less cytotoxic, this study suggests it can save money for the burn center. Future studies should directly compare the two topicals to determine if true differences in infection, healing, or length of stay that might offset or augment cost savings emerge.
57 Understanding the Burden of Burn Injury in Latin America & the Caribbean
Authors: Collier Zachary J , Bourcier Alexandre J , Naidu Priyanka , Magee William P , Potokar Tom , Gillenwater Justin
Published: March 2022

Introduction

Burn injuries are a global health problem disproportionately affecting low- and middle-income countries, especially in Latin America and Caribbean (LAC) where cooking methods, dangerous work conditions, and minimal housing regulations place people at increased risk of burn injury. Until recently, there was limited global epidemiological data on burn injuries. Following publication of the 2017 Global Burden of Disease (GBD17) database, we obtained objective and comparable data on burn injuries while specifically focusing on LAC countries.

Methods

Data from all 35 LAC countries were collected from GBD17 for fire, heat, and hot substance-related injuries to calculate burn incidence, deaths, and Disability-Adjusted Life Years (DALYs) with respect to country, age, and gender from 1990 to 2017. Incidence and deaths were reported as rates per 100,000 persons. Mortality rate was reported as a percentage of deaths-to-incidence. DALYs were reported in years per 100,000 persons. Incidence, death, DALY, and mortality rate trends were assessed using age-standardized, age-stratified, and gender-specific cohorts. All statistical analyses were performed using Excel.

Results

Over 27 years, LAC’s rates for burn incidence (-19%), deaths (-63%), DALYs (-62%), and mortality (-54%) all decreased with the greatest improvements seen in Brazil and Paraguay. All indicators improved around 15% more than the global averages during the same period with LAC’s rates 30-40% below global rates by 2017. The highest burn incidence (227 cases/100,000) was in Southern Latin America (Argentina, Chile, Uruguay). The Caribbean had the worst DALYs (124 years/100,000). In 2017, LAC accounted for 7% of global burns, 5.5% of deaths, and 5.1% of DALYs with Central America contributing the greatest numbers. For 27 years, Chile had the highest burn incidence but Haiti had the greatest death, DALY, and mortality rates of all LAC. Children under 14 years of age and males were disproportionately affected compared to other regional and global cohorts.

Conclusions

Despite a relatively greater reduction in burn severity and lifelong disability within LAC compared to the world, certain regions and countries exhibited significantly higher rates of burn injury, morbidity, and mortality. Central America (e.g. Costa Rica, Belize, Mexico) and the Caribbean (e.g. Haiti, Cuba) were particularly affected, comprising the majority of cases, deaths, and DALYs. This study provides essential analyses for developing regional and country-specific strategies to reduce the burden of burns through targeted interventions for prevention, workforce, and capacity building efforts.
62 The Impact of ICD10 on the Incidence of Abuse in the National Burn Repository
Authors: Hodgman Erica , Wharton Kristin
Published: March 2022

Introduction

Previously, cases of abuse may only have been coded as such when the investigation was complete, thus skewing the data available in the National Burn Repository (NBR) toward more severe or obvious cases of abuse. The introduction of the ICD10 coding system in 2015 brought with it the concept of “confirmed” and “suspected” cases of abuse. We hypothesized that the creation of these two categories might shift our understanding of non-accidental pediatric burn injuries.

Methods

We queried the NBR, a retrospective database maintained by the American Burn Association (ABA) which contains data submitted by all ABA-verified burn centers as well as some non-verified centers, for all children under the age of 18. Data were cleaned using e-codes where appropriate. To create equal samples, we created two cohorts: the ICD-9 sample comprises all children treated from 2012-2014, and the ICD-10 sample includes all children treated from 2016 to 2018. Data from 2015 were omitted as the ICD-10 coding system was introduced part way through the year.

Results

A total of 34,456 patients are included in the sample, including 18,783 (54.5%) in the ICD-9 group and 15,673 in the ICD-10 group. The most common causes of injury in both eras was scald (48.7% in ICD-9 and 55.2% in ICD-10), followed by fire/ flame (20.3% in ICD-9 and 20.9% in ICD-10). The overall rate of abuse (including both suspected and confirmed abuse in the ICD-10 group) was higher in the ICD-9 era than the ICD-10 era (4.2 vs 3.2%, p< 0.001). As seen in previous studies, children with injuries due to abuse were younger (median age 2.0 vs 3.0 years, p< 0.001), had a larger median burn size (3.0 vs 5.0%, p< 0.001), a longer hospital length of stay (2.0 vs 4.0 days, p< 0.001), and a higher rate of mortality (0.8 vs 0.5%, p< 0.001). In the ICD-10 cohort, only 17 cases were coded as “confirmed” abuse (0.1%) and 478 were coded as “suspected” (3.0%). In contrast, in the ICD-9 group, 789 patients (4.2%) were coded as being victims of abuse.

Conclusions

We expected that adoption of ICD-10, with its ability to yield increased data granularity, would yield a higher overall incidence of injury. Specifically, we expected more patients with smaller injuries to be included in the new “suspected” category, given the lower threshold to apply that diagnosis. However, this was not demonstrated in the NBR dataset, and in fact the overall incidence of abuse decreased. Given the added layers of complexity within the ICD-10 system, it is possible that the differences reflect challenges in coding cases of abuse rather than actual epidemiological changes.
67 Transient Dysphagia After Burn Injury in Children: An Under-identified Problem
Authors: Bui Trang , Parry Ingrid , Ng Pauline W , Romanowski Kathleen S , Palmieri Tina L , Greenhalgh David , Sen Soman
Published: March 2022

Introduction

Severely burn injured pediatric patients are at risk of dysphagia (difficulty swallowing) due to prolonged intubation or tracheostomy placement. To improve the early identification and treatment of dysphagia, we implemented a swallowing assessment protocol. We hypothesized that the swallowing assessment protocol is effective for identifying and treating dysphagia after prolonged intubation.

Methods

Between October 2016 and December 2020, pediatric burn patients with facial burn injuries, prolonged mechanical ventilation, tracheostomy, inhalation injury and/or anoxic events were placed on the swallowing protocol. The protocol included a Transitional Swallow Screen (TSS) performed within 24 hours after extubation or decanulation by an advanced practice swallow occupational therapist. If signs of dysphagia were noted, recommendations on diet consistency and treatment for positioning and feeding were implemented. Regular reassessments continued until the patient was determined to have regained premorbid swallowing function. Data on patient demographics, burn characteristics, dysphagia, treatment and outcome were collected. Descriptive statistics were used to describe the population, treatments and outcome.

Results

A total of 33 pediatric burn patients were included. Mean age was 8.1±5.9 years and TBSA was 48.1±26.8%. Median time from injury to swallow assessment was 45 (21-81) days. The majority of patients suffered from flame burns (70%). Almost all of the patients were intubated (97%) and 85% underwent a tracheostomy. Patients had a facial burn (73%), inhalation injury (24%) or anoxic injury (15%). Transient dysphagia was diagnosed in 79% of patients. Subsequent therapeutic procedures as a result of the TSS included: neurologic re-education (30%), swallow therapy exercises (55%), desensitization (42%), and patient/ family training and supervision (79%). All patients eventually returned to normal swallow and regular diet. This occurred at an average of 72.5+46.7 days post injury and 8.2+18.0 days post swallow assessment.

Conclusions

Pediatric patients with substantial burn injury may not only be at risk for aspiration but also have other forms of dysphasia that require intervention. Implementation of a swallowing protocol can identify patients who required further therapeutic intervention and can guide the recovery of safe swallowing and functional oral intake.
69 Early Post-operative Mobilization After Treatment of Burn Wounds with Autologous Skin Cell Suspension
Authors: Kelly Jenna C , DeJournette Emma C , Kahn Steven A
Published: March 2022

Introduction

Early mobilization has become popular in the literature and the benefits in critically ill patients are well-documented. However, early mobilization in burn care is undefined. Clinical practice guidelines regarding post-operative mobilization (POM) of patients with burn injury, especially after autografting, are limited, resulting in significant practice variance among burn centers. Furthermore, data on mobilization after treatment with autologous skin cell suspension (ASCS), is even more limited, and wider practice variation exists. We hypothesize early POM is safe and does not compromise healing or lead to graft loss.

Methods

A retrospective chart review was performed to examine mobility interventions utilized for patients, with mixed partial and full thickness burns, who received ASCS with polylactic acid sheet, with or without meshed splint-thickness skin grafting (STSG), over 6 months. Data included demographics, operative procedure, dressing, post-operative restrictions, POM date by burn therapy, and presence of graft loss ( >25% of grafted area with need for regrafting). The data was analyzed to corelate POM day and graft success. Initially, the authors utilized manufacturer splinting guidelines before becoming more judicious with aggressive early mobilization. Patients at risk of noncompliance and graft sheer were splinted.

Results

Fifteen patients were included in the study. In those patients, 25 body areas were grafted with 17 areas receiving ASCS with polylactic acid sheet and 8 areas additionally receiving STSG. On post-operative day (POD) 0, four areas were splinted and no range of motion (ROM) was performed at the joint. The authors splinted 3 out of 4 patients (75%) due to initial manufacturer splinting guidelines. The 4th patient was splinted due to compliance concerns. For the other 21 areas, active ROM, functional mobility and performance of activities of daily living with functional movement was allowed on POD 0. A burn therapist actively treated 64% of patients on POD 0-1 and 100% of patients were treated by POD 2. Minimal patchy graft loss (median 1.5%) was noted in 6 grafted areas including 1 area which crossed a knee despite immobilization. No graft loss was related to POM and was attributed to factors including infection or wound conversion and, by definition, no significant graft loss was found.

Conclusions

While the sample size is limited, this study suggests early POM of ASCS is safe and does not lead to graft loss. Considerations for mobilization techniques, such as ROM and functional mobility, should include joint involvement, presence of STSG with ASCS overspray, and other patient factors such as health literacy and compliance. Additional prospective studies should be dedicated to the examination of POM to develop clinical practice guidelines which can be widely utilized across burn therapy.
79 Factors Predicting Burn Survivor Group Interest in an Outpatient Burn Clinic
Authors: Ross Erin E , Colbath Rachel A , Yu Jeremy , Munabi Naikhoba , Gillenwater Justin , Yenikomshian Haig A
Published: March 2022

Introduction

Outpatient peer support groups have been demonstrated to help patients reintegrate with the community and improve self-acceptance following burn injury. Despite this, there is little data examining who desires participation. This is especially true for minority and socio-disadvantaged populations. The purpose of this study is to examine factors that influence desire to participate in burn survivor groups and actual participation rates.

Methods

Patients attending outpatient clinic were asked about participation in burn survivor group, interest in joining a group, and administered National Institute of Health Patient-Reported Outcomes Measurement Information System (PROMIS) Managing Emotions (ME) and Managing Social Interactions (MSI) questionnaires. Patient demographics, total body surface area burned (TBSA), initial hospital length of stay (LOS), and surgical intervention were collected from the medical record. While controlling for age and gender, indicators of injury severity and scores on PROMIS questionnaires were each examined for associations with survivor group interest using Firth or standard binary logistic regression.

Results

70 patients completed surveys in English (60%, 42/70) and Spanish (40%, 28/70). Current or past participation in burn survivor group was low (n=3/70, 4.2%), with greater interest in joining burn survivor group (n=20/66, 30.3%). Most patients interested in burn survivor group were Spanish speaking (65%, 13/20). Interest in joining a burn survivor group was associated with all collected measures of injury severity (Table 1). Scores on ME and MSI were not significantly associated with burn survivor group interest (ME p=.636, MSI p=.133).

Conclusions

There is a gap between interest and participation in burn survivor group, particularly among Spanish speaking patients. Patients with increase in TBSA, LOS, and undergoing surgery were more likely to express interest in burn survivor group participation. Interestingly, patients’ self-reported outcomes on emotional distress and interactions with others were not related to interest in burn survivor group.
84 Effects of Early, Non-excisional Debridement on Pediatric Burn Wound Re-epithelialisation Time
Authors: Griffin Bronwyn R , Bairagi Anjana , Holbert Maleea , Kimble Roy M
Published: March 2022

Introduction

Reported advantages of early excision for larger burn injuries include reduced morbidity, mortality, and hospital length of stay for adult burn patients. However, a paucity of evidence supports the best option for paediatric burns and the advantages of non-excisional (mechanical) debridement. This study aims to evaluate the association between early (< 24hours post-injury) non-excisional debridement under general anaesthesia with burn wound re-epithelialisation time and skin graft requirements.

Methods

A cohort study of children (< 17 years) presenting with burns >5% total body surface area, using prospectively collected state-wide pediatric burns' registry between January 2013 to December 2019. Primary outcomes were: time to reepithelialization (tested using survival analysis) and skin graft requirements, tested using binary logistic regression for odds ratios). Using depth and size, we performed a propensity matched dataset to analyse effects of early non-excisional debridement in the operating theatre.

Results

Overall, 392 children met eligibility (males 58.2%). When propensity matched, early non-excisional debridement under general anaesthesia in the operating theatre, significantly reduced the time to re-epithelialisation (15.0 (CI: 11.00-20.00) versus 20.0 (CI:13.5 – 31.00) days) and the odds of requiring a skin graft (OR:0.319 (0.125 – 0.812).

Conclusions

This study is the first to demonstrate that early non-excisional debridement under general anaesthesia in the operating theatre significantly reduces wound re-epithelialisation time and subsequent need for a skin graft in paediatric burn patients. Analysis suggests that ketamine procedural sedation and analgesia in the emergency department used for burn wound debridement is not an effective substitute for debridement in the operating theatre.
85 Changes in Burn Surgery Operative Volume and Metrics Due to COVID-19
Authors: Yoon Joshua S , Khoo Kimberly H , Akhavan Arya A , Lagziel Tomer , Cox Carrie A , Caffrey Julie , Hultman Charles S
Published: March 2022

Introduction

Due to COVID-19, hospitals have had to undergo drastic changes to operating room (OR) policy to mitigate the spread of the disease. Elective surgeries were cancelled, and some ORs were repurposed to help withstand a surge of COVID-19 patients. Given these unprecedented measures, we aim to look at the changes in operative volume and metrics of the burn surgery service at our institution.

Methods

An IRB-approved single-institution retrospective review was conducted by querying our institutional OR database. We obtained case lists and OR metrics for the months of March to May for 2019, 2020, and 2021, which correspond with pre-COVID, early COVID (period without elective cases), and late COVID (period with resumed elective cases). Inclusion criteria were cases related to burns. These cases were then divided into the following groups: excision only, grafting only, excision and grafting, laser scar procedures, secondary reconstruction without grafting or flaps, secondary reconstruction with grafting, and secondary reconstruction with flaps. Types of cases and operative metrics were compared amongst the three time periods.

Results

The total number of cases performed by the entire hospital during 2019, 2020, and 2021 was 2375, 1184, and 2265 respectively. During those times, the burn surgery service performed 174, 124, and 212 total cases (138, 103, and 114 burn related cases) respectively. Compared to the hospital, the burn service had a smaller decrease in volume during early COVID (28.7% vs. 50.1%) and exceeded pre-pandemic volumes during late COVID (+21.8% vs. -4.6%). There was a significant increase in excision and grafting cases in early and late COVID periods (41, 84, 74 respectively; p < .0001 and p < .002). There was a significant decrease in laser scar procedures that persisted even during late COVID (69, 0, 14 respectively; p < .0001). The projected and actual lengths of cases significantly increased and persisted into late COVID (p < .01). The average length pre-COVID and late COVID were 109.9 ± 78.5 and 138.2 ± 79.2 minutes.

Conclusions

COVID-19 related OR closures lead to an expected decrease in the number of overall cases and elective cases. However, there was no significant decline in the number of burn specific cases performed. The elective cases were largely replaced with excision and grafting cases and this shift has persisted even after elective cases have resumed. This change is also reflected in increased operative times.
92 ASCS Treatment Impact on Length of Stay Data and Costs for Patients with Small Burns
Authors: Carter Jeffrey E , Carson Joshua S , Rae Lisa , Saquib Syed F , Wibbenmeyer Lucy , Hickerson William L
Published: March 2022

Introduction

Introduction: Small burns with a total body surface area (TBSA) of < 20% account for the large majority (92%) of burn injury hospital admissions. Autologous skin cell suspension (ASCS) is a novel treatment for acute thermal burn injuries – including small burns -- that is associated with significantly lower donor skin requirements than split-thickness skin grafts, the traditional standard of care (SOC). The ASCS treatment indication was recently expanded from adult patients to include pediatric patients. Previously modeled analyses suggested that ASCS use is associated with a lower hospital length of stay (LOS) and costs savings versus SOC. This study evaluated whether real-world data (RWD) corroborate these findings in small burns and in both adult and pediatric populations.

Methods

Methods: Data were collected from January 2019 through August 2020 from 500 facilities in the United States. Adult patients (age ≥ 21) and pediatric patients (< age 21) receiving inpatient burn treatment with ASCS were identified and matched to patients receiving SOC based on sex, age, TBSA < 20%, and comorbidities. Based on typical BEACON model outcomes, LOS was assumed to account for 70% of total costs and was used as a proxy to assess the data. LOS was assumed to cost $7,554 per day. Mean LOS and costs were calculated for the ASCS and SOC adult and pediatric cohorts. The incremental revenue associated with changes in inpatient capacity was also analyzed.

Results

Results: A total of 151 ASCS and 2,243 SOC adult cases and 19 ASCS and 341 SOC pediatric cases were identified. In adults, the SOC cohort had a higher percentage of patients with TBSA < 20% than the ASCS cohort (82.9% vs. 55.0%). For small burns, sixty-three matches were made for each adult cohort, and seven matches were made for each pediatric cohort. For adults, LOS was 18.5 days with ASCS use and 20.6 days with SOC use (difference: 2.1 days [10.2%]). For pediatrics, the ASCS LOS was 18.6 days, and the SOC LOS was 21.4 days (difference: 2.9 days [15.4%]). This difference led to cost savings of $15,587.62 per adult ASCS patient. Total cost savings with ASCS adult patients were $22,268.03 per patient. The reduced LOS with ASCS adult patients resulted in an increased capacity of 2.0 inpatients per bed per year, which was estimated to increase hospital revenue by $83,894 per burn unit bed annually. Pediatric cost results and savings were similar.

Conclusions

Conclusion: This RWD analysis shows that small burn treatment with ASCS is associated with reduced LOS and substantial cost savings compared with SOC in both adult and pediatric populations, supporting the validity of previous model projections. ASCS use may also significantly increase hospital revenue related to increased inpatient capacity.
112 Developing Outpatient Registry to Capture Data Post Hospitalization
Authors: Schmoker Bethany A , Urban Shane , Wiktor Arek J
Published: March 2022

Introduction

Per the 2019 ABA reverification requirements, a burn center must see >75% of all inpatients (IP) who require an outpatient (OP) follow-up after discharge. In prior years, we utilized the inpatient registry and built a report to track patient follow-up. With the report, we were able to compare the number of Burn Clinic return patients against admissions to get the percentage. This process required hours of focused effort. We sought to optimize the process for determining IP follow-up at our ABA verified burn center. In addition, we hoped to better quantify the efficacy of our OP clinic.

Methods

An OP registry was developed in December 2019 utilizing an automated report from our electronic medical record (EMR) and imported into a custom built, secure, web-based software platform designed to support data capture for research studies. Employing various automation techniques, we were able to eliminate the need for manual abstraction by our burn registry team. Metrics tracked in the OP registry included: type of patient visit (New Patient, Return Patient, and Telehealth), diagnoses, zip-codes of patient residence, payer methods, and total number of clinic encounters per year. We collected data from January 2020 through the present, with 2020 being the first full year in the OP registry. The initial effort required to design, automate, and import data was approximately 18 hours. The report import takes approximately 5 minutes.

Results

The OP registry has given us the ability to create a multitude of graphs from the OP clinic data, like the one shown. During the review period our OP clinic saw patients from 19 different US states, encompassing 2,710 total OP visits. The median number of monthly OP clinic visits was 235 [IQR 210-246], see graph 1. The median number of clinic visits per patient was 2 [IQR 1-4]. The majority of clinic visits were return patients (55%, n = 1595), new patients (31%, n = 914), and telehealth visits (14%, n = 399). Finally, our analysis of the OP Clinic Registry demonstrated that we saw 82% (309/374) of inpatients that required follow-up care, exceeding the expected 75% by the ABA.

Conclusions

The creation of an automated OP registry can assist the tracking of discharged patients and reduce the amount of effort needed to track ABA required metrics. In addition, this OP registry can be expanded to track both IP and OP outcomes. This is crucial for quality improvement for the burn program as a whole.
500 Return To Work After A Burn Injury: Even The Small Burns Need Attention
Authors: Carmean Melissa , Joe Victor C , Bernal Nicole O , Burton Kimberly , Chin Theresa L
Published: March 2022

Introduction

An important part of burn recovery and reintegration involves the return to meaningful employment. Studies have determined that the workman’s compensation burn patient faces multiple barriers to return to work (RTW). Factors that increase time to RTW include increased TBSA burns, full thickness depth and grafting, burns to the hands and feet, and increased age. We hypothesize that patients with grafted burns, hand and feet burns, or psychological disorders following injury take longer to return to work.

Methods

A retrospective analysis was performed of burn patients seen in the outpatient burn clinic with work related injuries equal to or less than 5% TBSA, from 11/1/2016 to 5/31/2021. In addition to demographic data, also collected were locations of burns, dates of RTW, and positive PTSD and depression symptoms on screening.

Medians with interquartile ranges are reported due to nonnormal distribution, Wilcoxon Mann Whitney tests were performed using StataCorp. burn patients seen in the outpatient burn clinic with work related injuries.

Results

Of 118 patients, more injuries occurred in males (89%) than females with a median age of 36.5 years (IQR 26-49). The median TBSA was 1% (IQR .025-1.5) and the median time to return to work was 34 days (IQR 16-75). The 21 patients that were grafted took significantly longer to return to work (median 107.5 days; IQR 60-199.5) compared to 97 patients that were not grafted (median 28 days; IQR 13-59; p=0.0000]. Presence of a hand/foot burn trended towards increased time to RTW but was not significant, median 37 days (IQR 19-81) vs 26 days (IQR 14-61; p =.0306).

Patients with PTSD and depression (n=16) also took longer to return to work (Median 66; IQR 33-89.5) compared to patients (n=90) that showed no symptoms on screening (median 30.5; IQR 14-72; p=0.032).

Conclusions

The increased RTW for grafted, hand and foot burns is supported in the current research, however the addition of PTSD and depression and its interplay with RTW has not yet been fully vetted in determining return to work readiness. Within our population, positive screens for these psychological stressors profoundly affected their ability to return to employment. This study continues to validate the need for early screening and intervention in our population and the need to intervene as early as possible with psychological support services.