bluuebunny/crossref_metadata_2025 huggingface dataset:
Antiretroviral Therapy Intensification for Neurocognitive Impairment in Human Immunodeficiency Virus
Authors: Letendre Scott L , Chen Huichao , McKhann Ashley , Roa Jhoanna , Vecchio Alyssa , Daar Eric S , Berzins Baiba , Hunt Peter W , Marra Christina M , Campbell Thomas B , Coombs Robert W , Ma Qing , Swaminathan Shobha , Macatangay Bernard J C , Morse Gene D , Miller Thomas , Rusin David , Greninger Alexander L , Ha Belinda , Alston-Smith Beverly , Robertson Kevin , Paul Robert , Spudich Serena ,   the A5324 Study Team
Published: May 2023

Background

Neurocognitive impairment (NCI) in people with HIV (PWH) on antiretroviral therapy (ART) is common and may result from persistent HIV replication in the central nervous system.

Methods

A5324 was a randomized, double-blind, placebo-controlled, 96-week trial of ART intensification with dolutegravir (DTG) + MVC, DTG + Placebo, or Dual - Placebo in PWH with plasma HIV RNA <50 copies/mL on ART and NCI. The primary outcome was the change on the normalized total z score (ie, the mean of individual NC test z scores) at week 48.

Results

Of 357 screened, 191 enrolled: 71% male, 51% Black race, 22% Hispanic ethnicity; mean age 52 years; mean CD4+ T-cells 681 cells/µL. Most (65%) had symptomatic HIV-associated NC disorder. Study drug was discontinued due to an adverse event in 15 (8%) and did not differ between arms (P = .17). Total z score, depressive symptoms, and daily functioning improved over time in all arms with no significant differences between them at week 48 or later. Adjusting for age, sex, race, study site, efavirenz use, or baseline z score did not alter the results. Body mass index modestly increased over 96 weeks (mean increase 0.32 kg/m2, P = .006) and did not differ between arms (P > .10).

Conclusions

This is the largest, randomized, placebo-controlled trial of ART intensification for NCI in PWH. The findings do not support empiric ART intensification as a treatment for NCI in PWH on suppressive ART. They also do not support that DTG adversely affects cognition, mood, or weight.
Pancyclic And Hamiltonian Properties Of Dragonfly Networks
Authors: Huo Jin , Yang Weihua
Published: May 2023

Dragonfly networks have significant advantages in data exchange due to the small network diameter, low cost and modularization. A graph $G$ is $vertex$-$pancyclic$ if for any vertex $u\in V(G)$, there exist cycles through $u$ of every length $\ell $ with $3\leq \ell \leq |V(G)|$. A graph $G$ is $Hamiltonian$-$connected$ if there exists a Hamiltonian path between any two distinct vertices $u,v\in V(G)$. In this paper, we mainly research the pancyclic and Hamiltonian properties of the dragonfly network $D(n,h)$, and find that it is Hamiltonian with $n\geq 1,\,\,h\geq 2$, pancyclic, vertex-pancyclic and Hamiltonian-connected with $n\geq 4,\,\,h\geq 2$.
Association of Vascular Health Measures and Physical Function: A Prospective Analysis in the Framingham Heart Study
Authors: Sahni Shivani , Dufour Alyssa B , Wang Na , Kiel Douglas P , Hannan Marian T , Jacques Paul F , Benjamin Emelia J , Vasan Ramachandran S , Murabito Joanne M , Newman Anne B , Fielding Roger A , Mitchell Gary F , Hamburg Naomi M
Published: May 2023

Background

Dysfunction in blood vessel dynamics may contribute to changes in muscle measures. Therefore, we examined associations of vascular health measures with grip strength and gait speed in adults from the Framingham Heart Study.

Methods

The cross-sectional study (1998–2001) included participants with 1 measure of grip strength (kg, dynamometer) or gait speed (4-m walk, m/s) and at least 1 measure of aortic stiffness (carotid–femoral pulse wave velocity, brachial pulse pressure, and brachial flow pulsatility index) or brachial artery structure and function (resting flow velocity, resting brachial artery diameter, flow-mediated dilation %, hyperemic brachial blood flow velocity, and mean arterial pressure [MAP]) assessed by tonometry and brachial artery ultrasound. The longitudinal study included participants with ≥1 follow-up measurement of gait speed or grip strength. Multivariable linear regression estimated the association of 1 standard deviation (SD) higher level of each vascular measure with annualized percent change in grip strength and gait speed, adjusting for covariates.

Results

In cross-sectional analyses (n = 2 498, age 61 ± 10 years; 56% women), higher resting brachial artery diameter (β ± standard error [SE] per 1 SD: 0.59 ± 0.24, p = .01) and MAP (β ± SE: 0.39 ± 0.17, p = .02) were associated with higher grip strength. Higher brachial pulse pressure (β ± SE: −0.02 ± 0.01, p = .07) was marginally associated with slower gait speed. In longitudinal analyses (n = 2 157), higher brachial pulse pressure (β ± SE: −0.19 ± 0.07, p = .005), was associated with slowing of gait speed but not with grip strength.

Conclusions

Higher brachial artery pulse pressure (measure of aortic stiffness) was associated with loss of physical function over ~11 years, although we found no evidence that microvascular function contributed to the relation.
Exploring the gap between refugee-background communities’ needs and existing community-based physical activity programs in Australia
Authors: Hawkins Georgia , Malatzky Christina , Wilson Susan , Dingle Kaeleen
Published: May 2023

Physical activity programs run by local government, public health and not-for-profit sectors are a key public health strategy for improving rates of physical activity within local communities. However, these programs are underutilized. This is especially the case among members of refugee-background communities whose participation could have far-ranging and multilevel benefits. To explore how greater engagement among refugee-background communities with these programs could be fostered in Brisbane, Queensland, Australia, a qualitative study was undertaken from the perspectives of both community-based physical activity program providers and agencies involved in delivering services to refugee-background communities. This study involved a series of semi-structured interviews with a purposive sample of personnel from agencies that work with individuals and families from refugee-background communities and organizations that provide low-cost or no-cost physical activity programs and initiatives. Reflexive thematic analysis was used to interpret meaning from these data. Three themes relating to how participation in community-based physical activity programs could be improved among refugee-background communities were identified: improving cultural safety through intersectoral collaboration; confronting constraints imposed by the broader public health policy environment; and building capacity and empowering the community to diversify the sector. The findings highlight the importance of localized, deep-level intersectoral collaborations in bridging the gap between the health and social care needs of refugee-background communities and existing physical activity programs. However, a range of systems-produced barriers to the creation of such collaborations must be addressed to enable local actors to help mitigate and address the systemic exclusion of marginalized populations from participation in broader society.
Epigenome-wide methylation study identified two novel CpGs associated with T2DM risk and a network of co-methylated CpGs capable of patient’s classifications
Authors: Giri Anil K , Prasad Gauri , Parekatt Vaisak , Rajashekar Donaka , Tandon Nikhil , Bharadwaj Dwaipayan
Published: May 2023

Prevention of Type 2 diabetes mellitus (T2DM) pandemic needs markers that can precisely predict the disease risk in an individual. Alterations in DNA methylations due to exposure towards environmental risk factors are widely sought markers for T2DM risk prediction. To identify such individual DNA methylation signatures and their effect on disease risk, we performed an epigenome-wide association study (EWAS) in 844 Indian individuals of Indo-European origin. We identified and validated methylation alterations at two novel CpG sites in MIR1287 (cg01178710) and EDN2-SCMH1 (cg04673737) genes associated with T2DM risk at the epigenome-wide-significance-level (P < 1.2 × 10−7). Further, we also replicated the association of two known CpG sites in TXNIP, and CPT1A in the Indian population. With 535 EWAS significant CpGs (P < 1.2 × 10−7) identified in the discovery phase samples, we created a co-methylation network using weighted correlation network analysis and identified four modules among the CpGs. We observed that methylation of one of the module associates with T2DM risk factors (e.g. BMI, insulin and C-peptide) and can be used as markers to segregate T2DM patients with good glycemic control (e.g. low HbA1c) and dyslipidemia (low HDL and high TG) from the other patients. Additionally, an intronic SNP (rs6503650) in the JUP gene, a member of the same module, associated with methylation at all the 14 hub CpG sites of that module as methQTL. Our network-assisted EWAS is the first to systematically explore DNA methylation variations conferring risks to T2DM in Indians and use the identified risk CpG sites for patient segregation with different clinical outcomes. These findings can be useful for better stratification of patients to improve the clinical management and treatment effects.
Intermediate outcome for the single-stage surgical repair of aortopulmonary window associated with interrupted aortic arch
Authors: Nguyen Chi Hoang Linh , Nguyen Truong Ly Thinh , Tran Vinh Quang , Nguyen Mai Tuan , Mai Duyen Dinh , Doan Anh Vuong , Nguyen Quang Ngoc
Published: May 2023

OBJECTIVES

Aortopulmonary window (APW) associated with an interrupted aortic arch (IAA) is a rare cardiac malformation with significant mortality and morbidity. The goal of this study was to report the intermediate outcomes of single-stage repair concentrating on the surgical techniques and postoperative reintervention for this rare cardiac lesion.

METHODS

Eleven patients were diagnosed with IAA-associated APW and underwent single-stage surgical repair at Vietnam National Children’s Hospital.

RESULTS

The APW anatomy types were types I, II and III in 1, 4 and 6 patients, respectively. The IAA morphology was type A in 9 patients and type B in 2 patients. The median age was 27 [interquartile range (IQR) 6–79] days, and the median weight was 3.5 (IQR 2.8–4.5) kg. The aortic arch was repaired using direct end-to-side tissue anastomosis in 7 patients, and patch aortoplasty was performed in 4 patients. Six patients underwent APW closure with an intra-aortic baffle, and 5 patients required right pulmonary artery detachment and reimplantation. One early death occurred. Four patients required reinterventions: 1 patient required reoperation due to aortic stenosis and 3 required balloon angioplasty for either recurrent aortic arch stenosis (n = 1) or right pulmonary stenosis (n = 2) with a mean follow-up time of 3.1 years (IQR 0.5–4.3 years).

CONCLUSIONS

Single-stage repair of IAA-associated APW can be achieved with good survival outcomes in children. However, the need for repeat reintervention or reoperation remains high, and the growth of both the aorta and pulmonary arteries should follow carefully as the patient grows.

CLINICAL REGISTRATION NUMBER

VNCH-RICH-18–96
97 Burning a Hole in Our Pockets: 12 Year Trends of Medicare Reimbursement for Burn Procedures
Authors: Tiongco Rafael Felix , Atayeva Rena , Khan Iman , Puthumana Joseph , Hultman C Scott , Cooney Carisa , Caffrey Julie , Qiu Cecil
Published: May 2023

Introduction

Burn injuries cost the USA ~$976.6 million annually. Physician reimbursement has lagged despite years of lobbying by physician groups. The Centers for Medicare and Medicaid Services plan to cut physician reimbursement by 4.2% in 2023. Evaluating reimbursement data for hospital-based procedures is timely, including burn procedures. We hypothesized Medicare reimbursement trends for common burn procedures decreased from 2010-2022.

Methods

We obtained pricing data from the publicly-available Medicare Physician Fee Schedule Look-Up Tool for 26 Current Procedural Terminology (CPT) codes: “Burns–preparation of wound bed” (15002-15005), “Burns–split thickness skin graft” (15100-15101 & 15120-15121), “Burns–skin substitute” (15271-15278), “Cultured epidermal autograft” (15150-15152 & 15155-15157), and “Cell Suspension Epidermal Autograft” (15110-15111 & 15115-15116). We calculated percent differences for reimbursement; compound annual growth rate (CAGR); and percent differences for work, facility, non-facility, and malpractice relative value units (RVUs). Analysis was conducted in R 4.1.2.

Results

The three largest reimbursement increases were for CPT codes 15272 (24.6%), 15155 (23.7%), and 15003 (10.9%); the three largest decreases were for 15121 (-16.8%), 15120 (-6.1%), and 15275 (-5.0%). The three largest CAGR increases were for CPT codes 15272 (2.2%), 15155 (1.8%), 15274 (0.9%), and 15003 (0.9%); the three smallest were for 15121 (-1.5%), 15120 (-0.5%), and 15275 (-0.5%). Table 1 shows trends of RVUs.

Conclusions

Our 12-year analysis of Medicare reimbursement trends for 26 burn procedures demonstrated an overall increase in hospital reimbursement and parallel net decrease in physician work RVUs. Reimbursements were increasingly allocated away from surgeons to facility fees and malpractice insurance. Cultured epidermal autograft to the head, neck, hands, and feet (15155) saw the largest increase in Medicare reimbursement with no change in direct physician reimbursement while split-thickness skin grafts to the head, neck, & genitals (15120 & 15121) showed decreased rates. Future work is needed to understand why these trends are occurring to advocate against physician reimbursement cuts.

Applicability of Research to Practice

Studies contributing to price transparency allow stakeholders to focus on why burn surgeons are receiving lower reimbursements.
576 Pixel-Grafting and Negative-Pressure Moist Wound Chambers Improve Re-epithelization After Burn Injuries
Authors: Villalvazo Yadira , Humar Pooja , Bengur Fuat Baris , Loder Shawn J , Nerone Wayne V , Vagonis Alexandra , Shaaban Bahaa , Kokai Lauren E , Marra Kacey G , Eriksson Elof , Rubin J Peter
Published: May 2023

Introduction

Complex burns are a challenge, often requiring prolonged reconstruction. Management requires consideration not only to the skin but to underlying structures and often requires staged-reconstruction and revision for increasingly unsatisfactory results. This standard is expensive, limited by donor-site availability, and often impacts quality of life. Here we demonstrate the efficacy of single-staged minced skin grafting in an incubator-like microenvironment with a negative-pressure moist wound chamber device to achieve rapid epithelialization after burns.

Methods

Full-thickness burns were induced to female Yorkshire swine. Escharectomies were performed to the level of fascia after seventy-two hours. One group received standard of care skin grafting with a bolster dressing. In another group, split-thickness skin was cut into pixel size (0.3x0.3 mm) grafts, followed by application of either bolster or negative-pressure moist wound chamber dressing. Wounds were followed for 4-weeks with serial photography, ultrasound, and biopsies for histology.

Results

As early as one week, epithelialization started in the group with pixel grafts with negative-pressure moist wound chamber dressings with visible epithelioid islands on the wound bed granulation tissue. This progressed with a similar trend throughout the 4-week period eventually leading to near-complete epithelization and keratinization. There was reconstruction of trilaminar cutaneous architecture demonstrated by the presence of distinct, viable epidermal, dermal and hypodermal elements as well as viability of adipose on histology. Distinct differences in contour were noted between the bolster and negative-pressure moist wound chamber groups.

Conclusions

Minced grafting minimized donor burden and alleviated the need for graft orientation. In both the bolstered and negative-pressure moist wound chambers, pixel-grafts viably survived to form a viable basal layer. Use of positive-pressure (bolster) vs. negative-pressure moist wound chamber dressings demonstrated distinct differences in the convexity/concavity and topography of the singe-stage skin graft with critical implications for aesthetic reconstruction.

Applicability of Research to Practice

This study introduces the efficacy of a single-staged trilaminar reconstruction with the use of a negative-pressure moist wound chamber for complex burns. These findings support the potential for a new paradigm in the treatment of complex burns which allows for single-stage reconstruction with minimal donor site morbidity.
580 Burn Camp in the Midst of the COVID-19 Pandemic
Authors: ONeill Keisha , Smith Tiffany , Hollowed Kathleen , Lesher Aaron , Vezin Ross , Eubanks Ryan , Nord Al , Howell Rodney , Kahn Steven
Published: May 2023

Introduction

Previous literature has shown that pediatric burn camps provide numerous benefits to childhood burn survivors. Unfortunately, the COVID-19 pandemic resulted in the inability to host camp for fear of viral transmission to burn survivors and camp personnel alike. A comprehensive burn center, with assistance from the firefighter community, hosted its first burn camp since the onset of the COVID pandemic in August of 2022. A camp staff of 54 volunteers modified the previous camp processes to ensure camp was safe, fun and accessible to 20 pediatric burn survivors.

Methods

This is an academic short report that reviews the process changes necessary to host a safe pediatric burn camp in the midst of the COVID pandemic. All attendees and staff were required to show a negative PCR test result 48 hours prior to arrival at camp. COVID vaccination was encouraged in all participants, however, staff and patients were not required to be vaccinated. Daily symptom tracking was implemented immediately upon arrival to camp. All participants were assigned a thermometer, and daily temperatures and symptom monitoring was performed by the camp director. Masks were mandated when indoors or within close proximity or group activities. There was a quarantine plan in place in the case a camper or staff member became symptomatic, or tested positive for COVID. Lastly, the number of people per cabin decreased from 12 to 8.

Results

In the early planning phase of camp, it was discovered that some of the participants and staff were unable to obtain a PCR test prior to camp. Therefore, onsite testing was implemented to allow testing as the participants and camp staff arrived to camp. The onsite testing facility was available for the entirety of camp in the case anyone became symptomatic. Implementation of additional camp processes resulted in a successful and safe camp. There were no reported cases of COVID during or after camp.

Conclusions

As the Public Health Emergency from COVID-19 continues, group activities, such as summer burn camps, with medically vulnerable populations must be altered to protect all stakeholders. We described the steps taken by one burn-center-run camp that enabled children and firefighter volunteers to participate in the full burn camp experience. Plans for the 2023 burn camp are already in process, and the processes implemented in 2022 will be implemented in all upcoming camps to ensure the children and staff are safe from the transmission of COVID.

Applicability of Research to Practice

N/A
700 Implementation of an Intranasal Decolonization Protocol and Line Changing Policy in Adult Burn Patients
Authors: Yahia Adalah , Barber Katie , Herbin Shelbye , White Michael , Faris Janie , Laddaran Lester , Kowalski Katherine
Published: May 2023

Introduction

Reducing infection in burn patients can have a major impact on clinical outcomes. The purpose of this study is to evaluate the rate of bacteremia pre/post the implementation of a line change and nasal decolonization protocol.

Methods

This quasi-experimental study assessed adult patients admitted to a single center ABA verified burn center from August 2019 - August 2020 (pre-intervention group) versus September 2020 - September 2021 (post-intervention group). Patients must have received at least 1 round of intranasal decolonization treatment (mupirocin intranasal twice a day for 5 days and repeated every 30 days during hospital stay) during the post-protocol period. A line change policy was also implemented post protocol period for central and peripheral lines. Patients were excluded if they had a total loss of nasal alae, injury deemed nonsurvivable, or transitioned to comfort care within 72 hours of admission.

Results

A total of 558 burn patients were included, 324 patients in the pre-group and 234 post-group. There was no significant difference in comorbidities between the two groups. The majority of patients were admitted for an integumentary burn (87.6%) with the most common cause being flame (49.8%) or hot water contact (19.0%). Compliance with the decolonization protocol was appropriate for 87.6% of patients post-intervention. During the pre-intervention period, there were 18 (7.7%) positive blood cultures versus only 9 (3.8%) in the post-group (p=0.426). Gram-positive infections occurred in 44.4% of the pre-group and only 11.1% in the post-group (p=0.087). The rate of Gram-negative infections was similar between the pre and post-groups at 44.4% and 55.6%, p = 0.695. MRSA bacteremia was 44.4% of total Gram-positive bacteremia, with pre and post-intervention 4 (50%) vs. 0 (0%), p = 0.1. The median time of line placement to bacteremia pre-intervention was 7(5-12) days vs. post-intervention 11(6-14) days (p = 0.220). Hospital mortality between both periods was 9(3.8%) vs. 5(2.1%), p = 0.786. No significant difference was found in hospital LOS, ICU LOS, or discharge disposition.

Conclusions

Overall, this study showed a 50% decreased rate of MRSA bacteremia with the implementation of an intranasal decolonization protocol and a delay in Gram-negative bacteremia post implementation of a line change policy, potentially leading to a decrease in morbidity and hospital bloodstream infection-related costs.

Applicability of Research to Practice

Reducing infection rates can have a major impact on burn patient outcomes and lead to significant cost savings.
701 Impact of Alcohol and Methamphetamine Use on Burn Resuscitation
Authors: Kenney, MD Connor , Rizzo Julie , Coates Elsa , Serio-Melvin Maria , Aden James , Foster Kevin , AbdelFattah Kareem , Pham Tam , Salinas Jose
Published: May 2023

Introduction

Mortality associated with burn injuries is declining with improved critical care, including resuscitation. However, patients admitted with concurrent substance use have increased risk of complications and poor outcomes. The impact of alcohol and methamphetamine use on acute burn resuscitation has been described in single center studies, however, has not been studied since implementation of computerized decision support for resuscitation. The purpose of this study was to evaluate resuscitation volumes for patients with alcohol and methamphetamine use within a large prospective observational trial at 5 major US burn centers.

Methods

We performed an observational trial across five institutions with > 20% total body surface area (TBSA) burn, weighing >40kg that were resuscitated utilizing computerized decision support. Patients were evaluated based presence of alcohol, with a minimum blood alcohol level of 0.10, or positive methamphetamines on urine drug screen. Fluid volumes and urine output were examined over 48 hours and Wilcoxon Method was utilized to compare patient groups.

Results

A total of 296 patients were analyzed. 37 (12.5%) were positive for methamphetamine use, 50 (16.9%) were positive for alcohol use, and 209 (70.1%) with negative for both. Patients positive for methamphetamine received a mean of 5.30 ±2.63 cc/kg/TBSA, patients positive for alcohol received a mean of 5.41 ± 2.49 cc/kg/TBSA, and patients with neither received a mean 4.33 ± 1.79 cc/kg/TBSA. Patients with methamphetamine or alcohol use had significantly higher fluid requirements than those who were negative for both substances. In the first 6 hours patients with alcohol use had significantly higher urinary output in comparison to patients with methamphetamine use which had similar output to patients negative for both substances.

Conclusions

This study demonstrated that patients with alcohol and methamphetamine use had statistically significantly larger fluid resuscitation requirements compared to patients without. The effects of alcohol as a diuretic align with previous literature. However, patients with methamphetamine lack the increased urinary output as a cause for their increased fluid requirements. Methamphetamine’s neurologic and cardiovascular effects due to increased release of dopamine, serotonin, and norepinephrine are known. Further investigation is required to better understand the mechanism underlying the need for increased resuscitation after burn injury in patients positive for methamphetamines.

Applicability of Research to Practice

The impact of alcohol and illicit substances on burn care, especially during the initial resuscitation, aids providers in guiding early critical care.
708 Clinical Impact of a Revised Burn Resuscitation Guideline at an Adult Burn Center
Authors: Curry Dominick , Smith Susan , Hobbs Brandon
Published: May 2023

Introduction

The American Burn Association recommends volume resuscitation at 2-4ml/kg/TBSA; however, in practice, fluid resuscitation often exceeds these goals. Additional strategies used for burn resuscitation include the use of colloid rescue and high dose ascorbic acid (HDAA). In 2018, our institution moved from a fluid resuscitation strategy which included calculating fluid requirements using 4ml/kg/TBSA and HDAA infusion for burns > 30% TBSA to a strategy that calculated fluids using a 2ml/kg/TBSA with the removal of HDAA. Additionally, the guidance for colloid rescue was updated to provide specific time points for evaluation of the need for initiation of this intervention. The primary objective of this study was to compare outcomes of the new institutional resuscitation strategy to the previous one.

Methods

This was a retrospective cohort study evaluating outcomes for acute burn resuscitation between the previous institutional resuscitation guideline with the updated guideline. This study included adult patients admitted for burn injury with >20% TBSA between August 1, 2016, to September 30, 2021. The primary outcome was a composite safety endpoint which included incidence of acute kidney injury and intra-abdominal hypertension requiring intervention. Acute kidney injury was defined as a serum creatinine increase 1.5 times baseline. Statistical analyses utilized the Mann-Whitney U test for non-normally distributed continuous data and the chi-squared and Fischer’s exact test for categorical data. A p-value of < 0.05 was considered statistically significant.

Results

The final analysis included 43 in the pre-group and 52 in the post-group update. Baseline characteristics between the groups were similar. The primary composite safety outcome was non-statistically significantly lower in the post-guideline update group (39.5% vs. 28.8%, p= 0.273). Total fluid volume administered (3.74 ml/kg/TBSA vs. 2.97 mL/kg/TBSA, p=0.007) and hourly urine output within the first 24 hours (1.26 mL/kg/hour vs. 0.75 mL/kg/hour, p=0.007) were significantly lower in the post-group. No differences were observed in vasopressor use (32.6% vs 36.5%, p=0.63), vasopressor duration (70.3 hours vs. 50.4 hours p=0.24), or duration of mechanical ventilation (5.1 days vs 10.4 days, p=0.113).

Conclusions

The burn resuscitation guideline update resulted in significantly lower 24 hour- fluid volumes, without negative hemodynamic consequences.

Applicability of Research to Practice

The comparison of two resuscitation protocols provides evidence for other institutions to help optimize their resuscitation practice
725 Evaluating Wound Care Compliance, Healing and Perceptions in Burn Patients Discharged to Post-Acute Care Facilities
Authors: Osborn Suzanne , Garn Kristina , Mitchell Griselda , Neal Joya , Flores Juan , Richey Karen , Foster Kevin
Published: May 2023

Introduction

Prior research at our center demonstrated that 51% of all patients discharged to a skilled nursing facility (SNF) or acute rehabilitation center (ARC) had deterioration of their wounds. In that review, we were unable to identify specific patient factors associated with a worsening of wounds. We postulated that there was a relationship between specific facilities and outcomes, however due to the number of discharge facilities we were unable to analyze those relationships. Following our analysis, clinic personnel increased interactions with facilities to improve follow-up and communication. The purpose of this quality improvement project was to further explore factors that may influence wound healing in SNF and ARC environments and improve patient outcomes.

Methods

The review occurred over a 3.5-month period. Burn and non-burn patients residing at a SNF or ARC at the time of their clinic visit were included in the sample. A 10-item survey was administered to patients and a 5-item survey to the clinician. Wounds overall were deemed as “Improved” (IM) or “Worsened/No Change” (W/NC) and patients subsequently divided into these cohorts for analysis. Basic statistics were calculated.

Results

A total of 55 patients completed 81 surveys. The majority, 69% (n=38) had wounds that improved and 31% (n=17) showed worsening or no change. There were no significant differences between groups in wound etiology, facility type, dressing type / frequency or the absolute number of dressing regimes/patient. Facility compliance with clinic dressing orders was mediocre with 65% compliance in IM and 57% in the W/NC (p=.484). When asked if wounds were progressing as expected clinicians responded yes 97% of the time for IM and 36% for W/NC (p< .00001). When patients were asked if their facility had the needed dressing supplies, 84% (n=46) IM responded yes vs 61% W/NC (p=.029). There were no significant differences in patient understanding of wound care, if performed correctly, or ratings of pain control, appetite, restfulness, staff responsiveness, and overall care at the SNF or ARC.

Conclusions

An improvement in outcomes was noted between our first analysis and the current evaluation, this may be related to increased communication with facilities. Although the data demonstrated that prescribed wound care was not adhered to, there was no difference between groups. However, patient reports of inadequate dressing supplies at the facilities may be a factor in the progression of wound healing. While overall outcomes were improved, patients continue to experience an unacceptable rate of wound deterioration and further investigation is warranted.

Applicability of Research to Practice

Identifying interventions for patients sent to SNF and ARC facilities would improve wound outcomes.
734 A User-Centered Design Approach for a Burn Recovery Mobile Platform
Authors: Menge Kyler , Pham Tam , Carrougher Gretchen , Stewart Barclay , Kurien T Varugis
Published: May 2023

Introduction

People with burn injuries experience challenges in multiple domains including wound and scar management, pain/pruritus, psychosocial recovery, return-to-work, and community re-integration. Mobile software platforms can provide clear, concise, and consumable information across different stakeholder groups. These platforms require a user experience (UX) that values users’ expressed needs to maximize engagement with critical information. This study seeks to inform the UX for an outpatient mobile software platform to optimize recovery.

Methods

We performed semi-structured, in-depth interviews at a regional burn center with patients, clinicians, and carers to understand participant background, personal values, and requirements of a recovery platform. Interviews were transcribed and analyzed using grounded theory analysis and affinity mapping to surface major themes.

Results

Fourteen in-depth interviews (over 13.5 hours) were conducted with six patients, six clinicians, and two carers. Thematic analysis identified four principal themes and corresponding UX requirements: (1) Provide a clear path to recovery: need for easily understood temporal visualizations of recovery experiences in multiple domains. This includes outlining paths that list relatively individualized tasks critical for recovery. (2) Facilitate task habituation: UX to ease successful task performance such as daily schedules, reminders and integration of recovery tasks with activities of daily living. (3) Maintain motivation: recovery progress tracking, motivational messages and visualization of long-term recovery trends to maximize task adherence. Patients and clinicians identified goal-authoring and recovery progress as key motivators in performing recovery tasks. (4) Create a burn community: access to other people with burn injuries through integrated forums. Neither patients nor clinicians desired to directly communicate with each other through the platform, instead preferring existing electronic health record methods.

Conclusions

This study identified initial UX requirements for a person with burn injury-centered platform. There is strong support for temporal representations of recovery paths across multiple domains, UX design to facilitate and motivate users to stay engaged in performing critical recovery tasks, and access to the burn community.

Applicability of Research to Practice

Interviews of prospective users outlined four important features to include in the UX design of an online burn recovery platform.
735 Burns During the Pandemic: An Epidemiological Study of COVID-19's Impact on an Urban Burn Center
Authors: Choe Deborah , Won Paul , Abu-Ghazaleh Joshua , Collier Zachary , Gillenwater Justin , Yenikomshian Haig
Published: May 2023

Introduction

Due to stay-at-home and social distancing orders driving the advent of virtual workplaces and classrooms, we hypothesized the COVID-19 pandemic altered the epidemiology of adult and pediatric burn injuries presenting to our large urban burn center.

Methods

We retrospectively reviewed patients admitted to a metropolitan burn center during a 3-year period: one year prior to the COVID-19 pandemic (Control Year, 3/20/2019 - 3/19/2020) and the first 2 years of the pandemic (Year 1, 3/20/2020 - 3/19/2021; Year 2, 3/20/2021 - 3/19/2022). Data included burn etiology, severity, outcomes, and socioeconomic demographics.

Results

There were 404 burn patients admitted during the pre-pandemic year (Control Year). Fewer patients were admitted during the pandemic years (Year 1 = 339; Year 2 = 374). The average age of burn patients was similar across the three years (Control Year 39.9 ± 22.6; Year 1 40.4 ± 22.1; Year 2 41.8 ± 21.9 years) with an increasing percentage of males (61%; 68%; 66%) and undomiciled individuals (15%; 19%; 23%) getting burned. Rates of scald, chemical, electrical, and blast burns were similar across years with greater variations in rates of flame (35%; 40%; 37%), contact (5.0%; 8.0%; 3.8%), and friction (0.0%; 0.6%; 1.3%) burns. Survival rates (95%; 94%; 94%) and hospital length-of-stay (11.4 ± 16.5; 11.6 ± 14.4; 12.4 ± 17.7 days) were similar across the 3 years with slightly longer but variable ICU stays during the pandemic (8.2 ± 13.6; 10.1 ± 15.8; 11.5 ± 17.7 days).

Conclusions

Although the COVID-19 pandemic overwhelmed hospital systems and quarantine measures created altered home environments, our study suggests that burn severity and etiology were not significantly impacted by these changes. However, it does appear that the rate of burn injury decreased during the first year of pandemic lockdowns (Year 1) and started to increase towards pre-pandemic levels by Year 2 as lockdown restrictions were lifted. Flame, contact, and friction burns appeared to increase in frequency during Year 1 but normalized towards pre-pandemic levels by Year 2 as children returned to school. Analysis did show differences in ethnicity which may suggest the possibility of socioeconomic factors impacting who was getting burned during this time, but further studies are required to assess this potential disparity with greater nuance.

Applicability of Research to Practice

This study improves our understanding of the ongoing impact of pandemic restrictions on burn injuries in cities and may help develop better prevention, education, and intervention strategies.
739 A Review of Current Methicillin-Resistant Staphylococcus Aureus Decolonization Practices in a Pediatric Burn Population
Authors: Hockenberry Tiffany , Waterfield John , Richey Karen , Foster Kevin
Published: May 2023

Introduction

Methicillin-resistant staphylococcus aureus (MRSA) infections can result in severe sequela including death. Evidence-based practice guidelines exist for the universal decolonization of adult intensive care (ICU) patients. Evidence has not been established in the pediatric population, resulting in a knowledge gap regarding MRSA decolonization in children. Our practice is to test all patients upon admission for MRSA. Regardless of results, due to the immunocompromise of burn patients, all admissions are placed on a decolonization protocol that includes mupirocin ointment intranasally twice daily for five days. The repeated intranasal swabbing causes both discomfort and psychological distress for our pediatric patients. The purpose of this study was to evaluate current practice and the incidence of MRSA bacteremia in our pediatric population.

Methods

This was a retrospective review of all pediatric patients admitted to our center between January 2018 and August 2022. Patients who had mupirocin ordered for decolonization (YO) were compared to those who did not (NO). Basic descriptive statistics were calculated.

Results

A total of 508 individual patients had 519 admissions, YO 73% (n=379) NO 27% (n=140). There were no significant differences between groups for age, gender, race, ethnicity, admission diagnosis or mortality. Mupirocin was ordered at admission for 379 (73%) and administered per orders 74% of the time. YO patients were more likely to require ICU care 19% (n=73) vs 11% (n=16) (p=0.036) and mechanical ventilation 12% (n=46) vs 4% (n=6) (p=0.008). Length of stay (LOS) was longer for the YO group, 9.9 vs 5.11 days (p=0.008). The majority, 93% (n= 482) were admitted for burn injury, with a mean TBSA of YO 8.37 vs NO 5.86 (p=0.023). For YO, the mean number of doses to be administered, adjusted for LOS, was 6.71 vs actual doses given 3.8 (p < .0001). Overall incidence of MRSA positive blood cultures was 0.6% in the center but when controlled for setting it rose to 3% in ICU admissions. There were no positive blood cultures in non-ICU patients or the NO group. Three YOs had blood cultures positive for MRSA and had 80-90% of doses administered. Days to positive culture from admission were 6, 7 and 15.

Conclusions

Our review demonstrated that mupirocin was frequently discontinued before a full course was administered, yet the overall incidence of MRSA bacteremia was low, with all cases occurring in the pediatric ICU setting. These findings indicate that our current protocol does not perform well in this population and needs refinement. Universal decolonization in non-ICU pediatric patients is likely unnecessary.

Applicability of Research to Practice

An evidence-based protocol for children would improve antimicrobial stewardship in a vulnerable population and decrease psychological distress.
743 Educate Before You Operate: Improving the Informed Consent Process
Authors: Piatkowski Brian , Lee Jeanne , Strait Eli
Published: May 2023

Introduction

The informed consent process is a daily task for providers with a surgical patient population. In the burn population, informed consent is often presented by an intern or resident physician. Consent is comprised of surgical debridement with a multitude of options for coverage of their wounds. The current state of practice is a verbal overview of all the possible procedures that may be done to the patient’s wound(s). Patients often verbalize feeling overwhelmed with the amount of information on the consent and often have questions related to their procedure just before the brief of the operative case.

Methods

An educational video was developed that detailed the surgical procedure and the potential burn wound coverings. A 3-question survey was given to patients who have already been through the informed consent process. Survey metrics examined knowledge of consent when signed, the satisfaction of verbal explanation, and if a video would increase understanding. The video was given to the same patients to watch. After the video was viewed, those patients were then again surveyed. Providers were also given a 3-question survey before viewing the video. Survey metrics examined comfort of consent, knowledge of procedures, and if the video would increase patient understanding of consent topics. The providers were then surveyed after watching the video.

Results

Initial post-implementation data shows that patients and providers have increased comfort and knowledge in the informed consent process. Patients show an 80% increase in understanding of consent, a 72% increase in satisfaction with video vs verbal overview, and a 97% increase in satisfaction with material viewed. Provider data shows a 65% increase in the comfort of consent, a 64% increase in knowledge of procedures, and a 97% increase that the video will help patients understand their consent. This shows that this evidence-based project is an improvement from the current standard of practice.

Conclusions

The informed consent process is an opportunity for providers and patients to have a moment of discussion. It is a pivotal point in which a patient and a provider determine the next step of their care. The patient must have clear communication and education regarding the procedures to which they are consenting. It is also a discussion where a provider can provide education and support at what is an overwhelming time for patients in their hospital stay.

Applicability of Research to Practice

Implementation of a standardized audio/video teaching method for burn surgical patients is an effective way to increase patient and provider satisfaction regarding the informed consent process. Implementing this educational tool is a cost-effective and simple way to educate burn patients before their surgical procedures. There is an overall improvement in patient satisfaction and increased satisfaction in the providers who obtain the consent.
745 Caring for Infants, Centenarians, and Everything in the Middle
Authors: Ha Aemilio , Rita Frek , Grywalski Michelle , Chin Teresa , Bakas Mira , Godes Natalya
Published: May 2023

Introduction

Age specific considerations are integral part of quality care. Several burn units care for all age groups in a single unit, needing additional resources and infrastructure to provide quality care for extremes of age.

Methods

An anonymous online survey was conducted among the multidisciplinary burn team members of a burn unit that cares for both pediatric and adults. Data for the last 4years found that 12-18% of all burn admissions were 2years or less, while 5-6% of burn admission were of over 75 years of age.

Results

45 members responded to the survey, including 56 % RNs and the remaining included therapists, pharmacist, psychologist, social worker, child life specialist, and case manager. The results showed that team members felt more comfortable caring for geriatric patients than pediatrics. Staff members reported higher importance for having intubated pediatric patient with leverage of 1:1RN assignment as well as daily rounding by pediatric intensivist and pediatric pharmacist. Majority (73%) of respondent s reported good or excellent in their assessment, skill, knowledge, and communication ability for caring pediatric patients aged and 2 and below. Elements that reported to be helpful for caring extremes of age in the order of its importance were weekly multidisciplinary rounds, burn debriefs of selected cases, monthly performance improvement meetings/ follow ups, weekly psycho social rounds and journal clubs. Low volume high acuity patient's care was kept up to date through various interventions which were prioritized by the respondents in the order of age specific continuing education classes, professional conferences, simulation/ skills day, and journal clubs.

Conclusions

The current process shows satisfactory comfort level for most of the team members to care for all age groups. Availability of pediatric and geriatric specialty professionals along with sufficient supply of age specific equipment, and ample educational opportunities were noted by the respondents as the key to providing quality care for all age groups in a single setting.

Applicability of Research to Practice

The current model may be continued with sustainment of different specialty services, educational resources, and age- specific supplies and equipment.
746 Burn Provider Perceptions Before and After Implementation of a Pain and Sedation Clinical Practice Guideline
Authors: Dryer Vince , Smith Kathryn , Paine Rosemary , Kearney Raechell , Falank Carolyne , Carter Damien , Billert Alexandra , Murray Lisa
Published: May 2023

Introduction

Pain and sedation management is a crucial yet challenging aspect of burn care. We sought to survey a multidisciplinary group of nurses (RN), physicians (MD), advanced practice providers (APP), and therapists (PT/OT) to determine perceptions of pharmacologic pain and sedation management before and after the implementation of a standardized clinical practice guideline (CPG) at our institution.

Methods

A 28-question survey assessing knowledge, pain and sedation practices, and therapy participation was distributed to all intensive care unit (ICU) and non-ICU burn care providers at our institution before (n=135, 2019) and after (n=185, 2022) CPG implementation. Comparison of proportions was calculated using Chi-squared test.

Results

Survey response was 61 (45%) before and 51 (28%) after CPG, with 18 participating in both. Most respondents (63%) had 0-5 years of experience caring for burn patients. Patients were perceived to have significant background pain >50% of the time by 69% of RN before vs 55% after (p=0.26). Intermittent opioid boluses were preferred to continuous infusions in intubated patients before (57%) and after (59%) CPG implementation (p=0.87). Perceived utilization of multimodal pain management was high (82%) amongst all responders, except for ICU RN (53%) (p=0.05). While < 30% of all providers believed analgesics were underutilized for procedural pain, non-ICU RN consistently reported patients were in significant pain 50-75% of the time during procedures (78% before vs 85% after, p=0.61). Perceptions of sedative underutilization were unchanged before and after CPG (ICU RN 58% vs 33%, p=0.15; non-ICU RN 69% vs 71%, p=0.91; MD/APP 69% vs 71%, p=0.95). PT/OT reported pain as the most common reason for nonparticipation in therapy sessions with one-third reporting underutilization of analgesics in both surveys. In the after survey, 50% agree we manage pain effectively. Areas for improvement included open communication between disciplines regarding pain and sedation plan, increased use of intermittent sedatives compared to continuous, and less IV opioid utilization with more focus on nonopioid therapy. Fifty percent of after survey respondents were aware of the CPG.

Conclusions

Implementation of a CPG did not change perceptions of pain and sedation at our institution. This may be due to limited education surrounding CPG and overall lack of utilization. Future efforts should focus on education and communication between disciplines.

Applicability of Research to Practice

Variability in provider perceptions of pain and sedation management in patients with burn injury remain despite implementation of a CPG.