bluuebunny/crossref_metadata_2025 huggingface dataset:
67 Methamphetamine-Positive Burn Patients: Not Just an Urban Problem
Authors: Proffitt Allison , Sojka John H , Heard Jason , Sen Soman , Palmieri Tina L , Greenhalgh David G , Romanowski Kathleen S
Published: April 2024

Introduction

Our previous research on burn patients who test positive for methamphetamines (MA) demonstrated that these patients come from areas with higher rates of poverty and lower median incomes. Our current study sought to replicate our previous results as well as further examine the communities from which our patients come with respect to their Social Vulnerability Index and Rural vs. Urban background. We hypothesized that MA-positive patients at our regional burn center would come from more highly disadvantaged urban areas.

Methods

Following IRB approval, a retrospective chart review was conducted using electronic medical records for burn patients admitted from January 2015 to December 2019. MA-positive patients were matched with MA-negative patients based on age and total body surface area (TBSA) burn. Data on Poverty levels, Median Income, Social Vulnerability Index (SVI), and Rural-Urban Commuting Areas were determined using patients’ home zip codes. Analysis was conducted with SAS statistical software, version 9.4 (SAS Institute, Cary, NC, USA) using Student t-test, Chi-square, Fisher Exact, and Wilcoxon 2-sample tests. Results are presented as median (interquartile range).

Results

We matched 107 MA-positive patients with 107 MA-negative controls based on TBSA burn and age. The median age of all patients was 49 (20) years old, and the median burn size was 22.3% (32.5). MA-positive patients experienced higher rates of Poverty (21.4% (13.1) vs 12.8% (12.4); p< 0.0001), increased SVI (0.74 (0.42) vs 0.55 (0.47); p=0.0002) and lower Median Incomes ($49,520 (23,447) vs $59,693 (32,075); p< 0.0001) than their MA-negative counterparts. There was no significant difference between Urban and Rural backgrounds for MA-positive and MA-negative patients (p=0.6). Most MA-positive patients came from Urban locations (16.82% Rural vs. 83.18% Urban), as did most MA-negative patients (19.63% Rural vs. 80.37% Urban). Meth-positive patients were more likely to sustain burns in an incident of suspected assault or abuse (7 vs. 2 patients) and less likely to be burned in a work-related incident (1 vs. 13 patients). Despite these differences in socioeconomic status, MA-positive patients had no significant increase in Length of Stay, Hospital Charges, or Mortality.

Conclusions

MA-positive patients come from both rural and urban areas, areas with increased poverty, lower median incomes, and increased social vulnerability when compared to MA-negative patients. Despite this MA use, by itself, does not appear to change outcomes following burn injury.

Applicability of Research to Practice

Patients with MA use come from both rural and urban areas and are often more socially disadvantaged than patients who do not use MA. These factors should be considered in inpatient care, disposition, and follow-up plans.
87 Impact of Skin Substitute Use for Burns: An Analysis of the ABA National Burn Repository
Authors: Crombie Roselle , Witherel Claire
Published: April 2024

Introduction

Skin substitutes provide unique utility for the management of thermal injuries over the last 20 years and have evolved into over 75 available technologies today. They are used for patients where insufficient autograft was lacking. Despite demonstrated long term safety and efficacy, use of skin substitutes remains controversial with respect to health economic metrics, including length of stay (LOS), complications, timing of application, number and types of procedures, resource use, and depth of burn. Clinical studies investigate skin substitute use in smaller burns (~20% TBSA) or in some anatomical regions (face, neck), but few address impact within a large national registry inclusive of all burn sizes and locations. The goals of this study were to investigate skin substitutes use for burns over the last 13 years and to elucidate where skin substitutes have the most utility in the burn care continuum.

Methods

NBR data from 2008-2021 were analyzed (n = 388,775 patients). Surviving patients treated with a dermal regenerative graft during their care were identified via ICD-9 and ICD-10 codes (n=41,785 patients) and to show all surviving patients only and eliminating patients with data missing (n=32,428). Metrics including patient demographics (age, sex, race, comorbidities, burn degree, burn location/area) and outcome measurements (length of stay (LOS), total body surface area (TBSA) (2nd, 3rd, and combined), complications, resources, days in the ICU, number of procedures, number of excisional and non-excisional debridements). Additional analyses included determining the percentage of 2nd and 3rd degree burns (normalizing against total) and normalizing patients’ LOS per TBSA and investigating differences between skin substitute patients where their treatment was applied early (less than or equal to 7 days) or late (greater than or equal to 8 days).

Results

Patients with the majority of their burn being 3rd degree and their skin substitutes applied within the first 7 days of admission, particularly for 10-20% TBSA and 20-40% TBSA were associated with a significantly lower LOS/TBSA compared to the same patients who received their skin substitute 8 days or later. Skin substitute use was associated with LOS/TBSA over 1.5 for all size burns when applied early and over 1.7 when applied late (Fig1).

Conclusions

This study illustrates the first analysis of the ABA NBR investigating skin substitute use in burns, including high TBSA burns. Previous studies have limitations and overestimation of the traditional rule-of-thumb of LOS/TBSA near 1, including confounding variables such as age, complications, inhalation injury, and depth of burn. This study also shows that the care algorithm should be considered in outcome measures; future analysis will investigate this patient cohort to further understand the clinical and health economic implications of skin substitute use for burns.

Applicability of Research to Practice

Knowing when to apply a skin substitute
90 Outcomes of Minimally Invasive Excision with Epidermal Autografting in Pediatric Partial Thickness Burns
Authors: Maxey Julia , Wampler Mallory , Elkady Djoni , Williamson Kelly , Lou Richard B , Khandelwal Anjay
Published: April 2024

Introduction

The traditional approach to pediatric deep partial thickness burns has been a “watch and wait” attitude with frequent dressing changes, primarily due to evidence that pediatric burns will often heal, and that early debridement leads to removal of non-viable tissue. However, there is still significant morbidity with delayed healing, increased pain and dressing changes, prolonged hospital stays, added cost and hypertrophic scarring. Dermabrasion is a minimally invasive excisional technique that may preserve viable dermis while epidermal autografting can be used for partial thickness burns to facilitate wound healing. In an effort to improve outcomes, the authors evaluated the outcomes of dermabrasion with epidermal autografting in the pediatric population.

Methods

A retrospective review of pediatric patients (< 18 years old) who underwent minimally invasive excision using dermabrasion with epidermal autografting as the only primary surgical intervention between January 2022 and July 2023 was performed. Patient information collected included: demographics, burn depth, mechanism of injury, percentage of total burn surface area (%TBSA), time to operating room (OR), length of stay (LOS), narcotic use (morphine equivalents), postoperative complications, need for autografting, and number of dressing changes requiring sedation. This was compared to previously conservatively managed patients as well as published historical data.

Results

A total of 46 patients [mean age: 4.95 years (range: 0.04-18)] were examined with an average %TBSA of 7.45 (range: 0.3-19.75). The majority of patients sustained a scald injury (74%). Most patients (66%) had involvement of critical areas including the hands, face, feet or genitalia. Approximately 40% of the patients had Fitzpatrick Skin Type V-VI. The average time to OR was 2.7 days (range 0-8). Average length of stay/%TBSA was 0.45 days. The total number of dressing changings requiring sedation was 1.6 (range 0-7). Almost all patients (96%) had wounds that were >90% re-epithelialized by postoperative day 10. When compared to historical data, time to epithelialization was decreased by 5 days, grafting rate was decreased (11.5% to 6%), opiate usage was decreased in half (0.3 MME/kg/day to 0.15 MME/kg/day), infection rate was reduced to zero, and average LOS was decreased from 10.4 days to 3.6 days).

Conclusions

Within the pediatric population, minimally invasive excision with epidermal autografting may be superior to conservative management with decreased length of stay, fewer dressing changes, decreased infections, decreased need for autografting and decreased opiate consumption. Length of stay can be significantly decreased with earlier operating room availability and swift decision making.

Applicability of Research to Practice

There may be a viable alternative option to the traditional “watch and wait” approach to pediatric partial thickness burns.
125 Pain Management in Adult and Pediatric Burns: A Global Survey of Burn Care Providers
Authors: Gibson Cameron , Dewey Morgan , Baker Kori , Mueller Scott W , Balstad Blaire
Published: April 2024

Introduction

Pain management for burn injuries is an essential component of compassionate burn care. Practices may vary by region or socioeconomic status. This study aimed to assess current pain management practices in burn patients globally.

Methods

An online survey regarding the availability and use of drugs for burn pain management was sent to members of the International Society for Burn Injuries (ISBI) via email and shared in WhatsApp groups comprised of burn professionals. The primary outcome was to provide a cumulative data representation to increase knowledge regarding the state of global burn pain management. Data was analyzed for descriptive statistics by region and socioeconomic status.

Results

113 out of 197 surveys were completed (57%) from 44 different countries. 80% of respondents were MD’s, 15% RNs, and 5% other. By region, 38% were from North America, 21% from Asia, 14% from Africa, 12% from Europe, 9% from South America and 5% from Oceania. By socioeconomic status, 50.4% were from high-income countries (HICs), 22% upper middle-income countries (UMICs), 24.8% low middle-income countries (LMICs), and 2.6% low-income countries (LICs). Most respondents treat both adults and pediatric patients (65%) with an equal number caring for adults or pediatrics only (18% each). The most common drug for managing background pain was paracetamol for all patients and for wound care in pediatrics. Oral and IV opioids were unavailable at 29% and 16% respectively in LMIC/LICs, 36 and 8% in UMICs, and 5.3% for both in HICs. For wound care, IV opiates, paracetamol and benzodiazepines were the most common in HICs and UMICs, while paracetamol was the most common in LMICs/LICs. Ketamine and propofol were used more frequently in UMICs for wound care in adult patients. Non-pharmacological methods were rarely used in adults and in a minority of children.

Most respondents were aware of a pain guideline (72%) and have a pain management protocol at their facility (65%). HICs reported pain at their facility being managed “well” or “very well” (70%) versus half of respondents from UMICs (52%) or LMICs/LICs (50%). Only 11% of respondents from HICs thought pain was managed “somewhat poorly” or “poorly,” versus 16% of UMICs and LMICs/LICs. Those who reported having a protocol for pain management or who were aware of pain guidelines reported better perceived pain control for their patients compared to those who did not (p < 0.05).

Conclusions

Practice around pain control for burn injuries and wound care vary mostly by socioeconomic status and drug availability. Perception of adequate pain control is associated with socioeconomic status, availability of drugs and having a pain protocol.

Applicability of Research to Practice

Burn centers can optimize pain management by establishing standard operating procedures based on existing guidelines. Centers with pain protocols should consider sharing them with other sites to use as a template.
126 Predictors of Lengthened Admission in Adult Burn Patients, a Secondary Analysis of 1796 Cases
Authors: Zhu Xi Ming , Tedesco Diana , Gallo Lucas , Shahrokhi Shahriar , Jeschke Marc G
Published: April 2024

Introduction

Existing research has examined the relationship between the amount of total body surface area (TBSA) burn and length of stay (LOS). As a result, the conventional ratio of 1day LOS/1% TBSA ratio has been updated to 1.5days LOS/1% TBSA. In this study, we aim to elucidate patient and injury characteristics that affect our prognostic indicator, leading to a prolonged LOS.

Methods

This was a secondary analysis of a cohort study of surviving patients admitted to a tertiary adult burn center between January 1, 2006, and June 30, 2021. Adult patients less than 60 years of age were stratified into expected LOS ( < 1.5 days/%TBSA) and greater than expected LOS (>1.5 days days/%TBSA). Patient demographics, TBSA, burn etiology, inhalation injury, pre-admission co-morbidities, and in-hospital complications were tabulated Logistic regression was performed using IBM SPSS Statistics 29 and Stata Statistical Software: Release 18.

Results

1796 patients with a mean age of 39 years were included for analysis of the adult population. 905 patients had the expected LOS/TBSA ratio, and 891 exceeded this ratio. Univariable analysis indicated patients with greater age [1.02 (1.01 – 1.03) p < 0.0001], female sex [1.84 (1.49 – 2.27) p < 0.001], diabetes [1.50 (1.00 – 2.24) p = 0.047], psychiatric illness [1.44 (1.11 – 1.88) p = 0.006], and those who experienced complications (such as infection, graft failure, pneumonia, sepsis) [1.44 (1.20 – 1.74) p < 0.0001] during admission were more likely to exceed their predicted LOS.

Multivariate analysis found that greater age [1.02 (1.01 – 1.03) p < 0.0001], female sex [1.64 (1.30 – 2.06) p < 0.0001], inhalation injury [2.18 (1.50 – 3.15) p < 0.0001], psychiatric illness [1.50 (1.01 – 1.87) p = 0.04], and complications [2.69 (2.11 – 3.43) p < 0.0001] were contributing factors that increased the likelihood of patients exceeding predicted LOS. Diabetes was not a statistically significant contributor.

Conclusions

Progress has been made to identify patient and injury factors that increase the likelihood of increased LOS for adult patients with burn injuries. This provides valuable data for physicians to better assess patients and improve their quality of care.

Applicability of Research to Practice

Identification of key burn patient characteristics aids in prognostication. Determining length of stay aids with coordination of patient care with the multi-disciplinary team.
134 Early Split-Thickness Autografting over a Collagen-Elastin Dermal Matrix Aids in Vascularization and Decreased Contraction
Authors: Powell Heather M , Blackstone Britani , Swanson Susannah , Mukka Naomi , Campbell Autumn , Everett Zachary , Bailey John Kevin
Published: April 2024

Introduction

The dermis plays an important role in skin biomechanics and epidermal homeostasis. Following deep cutaneous injuries, restoration of the dermis is key for optimal functional and aesthetic outcomes. To regenerate a healthy, vascularized dermis, several dermal substitutes have been designed. The timing of split-thickness skin graft (STSG) application over these dermal substitutes is critical to success yet has not been studied systematically for some matrices.

Methods

To understand the impact of STSG application timing, a collagen-elastin dermal matrix (CEDM) was applied to 2 x 1 in full-thickness acute surgical wounds created on the dorsum of red Duroc pigs following an IACUC approved protocol (10 sites per pig, 5 pigs). CEDMs were applied to the sites after which sites were grafted with meshed (1:1.5) and expanded STSG immediately or 4, 8 or 14 days following CEDM application. Sites without a CEDM beneath the STSG served as controls. Non-invasive measurements of tissue perfusion and contraction were collected at each site along with normal pig skin (NPS) at all timepoints with transepidermal water loss, pigmentation, erythema, contraction, and biomechanical properties quantified following grafting. Values were normalized to NPS for each pig. Biopsies (4mm) were collected and stained/immunostained to examine inflammation, blood vessel formation and dermal remodeling. All quantitative data were analyzed using a One-Way ANOVA with a Tukey posthoc test.

Results

Engraftment rates were high when CEDM were grafted on D8 or earlier (> 97% engraftment); however, engraftment was more variable when CEDM were grafted on D14. There was no delay in re-establishment of epidermal barrier function as a result of the presence of the CEDM or as a function of application time. Four days post CEDM application, all groups were ~4-fold more perfused than normal pig skin. Following grafting, perfusion reduced to 2-fold NPS within one week of grafting. Perfusion within the CEDM remained high (4.5-5.2-fold NPS) until STSG application with the D14 group remaining at elevated perfusion levels through 6 weeks post-injury. Graft area was inversely related to time of grafting with CEDM sites grafted on D0 105.2% original area whereas sites grafted at day 14 post injury 70.5% original area (control sites 107.4% original area at week 12).

Conclusions

In a porcine model, earlier application ( < 8 days) of STSGs over CEDMs was related to greater levels of engraftment and reduced levels of scar contraction. The CEDM became rapidly vascularized which may aid in the ability to be grafted immediately or soon after application.

Applicability of Research to Practice

Data suggest immediate and early application of STSG over CEDMs does not result in graft loss or delayed re-epithelialization and may lead to improved outcomes.
135 Evaluation of Autologous Skin Cell Suspension on Re-epithelialization and Repigmentation in Pre-clinical Models
Authors: Bush Katie A , Kashgari Ghaidaa , Jahid Sohail , Powell Heather M , Kahn Steven A
Published: April 2024

Introduction

The autologous cell harvesting device prepares an autologous skin cell suspension (ASCS) from a thin skin sample at the point of care. This study reports on advanced cellular characteristics of ASCS and provides pre-clinical evidence of functional regeneration of the epidermis of full-thickness injuries including re-epithelialization, repigmentation, basement membrane formation, and barrier function.

Methods

Autologous skin cell suspension was prepared from excised discarded healthy donor tissue. Cellular density, viability, phenotypes, apoptotic activity, and number of aggregates were analyzed over 10 donors. To evaluate functionality, two pre-clinical model systems were used. The first system utilized an in vitro model composed of a 3D living dermal equivalent containing viable collagen and fibroblasts. ASCS was applied to the dermal equivalent and cultured over 21 days. The second model was an in vivo model, using full-thickness excisional wounds in Yorkshire pigs. ASCS was prepared and applied onto the wound bed in combination with 3:1 meshed autograft. Healing outcomes were recorded through visual observations and histology was assessed for epidermal morphology (cell localization, stratification), re-epithelialization, proliferation, and basement membrane formation.

Results

ASCS prepared from 4 cm2 donor skin had a mean of 2.41E6±1.03E6 total cells/ml and from 24 cm2 donor skin had a mean of 2.76E6±6.80E5 total cells/ml. The majority of cells found in ASCS were non-apoptotic single cells. Advanced phenotyping data suggests presence of basal keratinocytes and activated keratinocytes, both known to play a role in wound healing and epidermal regeneration.

The in vitro model demonstrated reconstruction of an epidermal layer with basement membrane formation, and localization of melanocytes and proliferative cells at the dermal-epidermal junction. Additionally, this model system demonstrated the functionality of the melanocytes, as pigmentation was macroscopically observed at 21 days.

Full-thickness wounds treated with ASCS+mSTSG in the porcine model successfully re-epithelialized, with a thin layer of epidermal cells present in the interstices of the expanded 3:1 mSTSG seen as early as 3 days post-wounding. At 6 days, average percent re-epithelialization in the interstices was 91%. The regenerated epidermis contained highly

Conclusions

These pre-clinical models demonstrate the functionality of ASCS and ability to regenerate a functional epidermis when the appropriate environment and signaling cues are present.

Applicability of Research to Practice

This data provides scientific evidence supporting clinical results obtained when ASCS is used in conjunction with a mSTSG for the treatment of full-thickness wounds.
514 GPT-4 Passes the Advanced Burn Life Support and Advanced Trauma Life Support Exams
Authors: Egro Francesco , Arellano Jose Antonio , Liu Hilary , Alessandri-Bonetti Mario , Donovan James , Corcos Alain C , Ziembicki Jenny A
Published: April 2024

Introduction

The Advanced Burn Life Support (ABLS) and Advanced Trauma Life Support (ATLS) exams assess medical professionals’ ability to effectively evaluate, stabilize, and treat burn and trauma patients in emergency situations. Recently, there has been a growing prevalence of Artificial Intelligence (AI)-powered Natural Language Processing (NLP) chatbots, giving rise to the question of how these technologies may be integrated into medical education. To determine if LLMs could serve as clinical or educational tools for burns and trauma, this study assessed their performance on the ATLS and ABLS exams.

Methods

GPT-3.5, Bard, and GPT-4 were prompted to answer the 2023 ABLS exam (50 questions) and three ATLS 10th edition exams (40 questions each). Answers produced by the AI chatbots were compared to the answer key provided by the American Burn Association (ABA) American College of Surgeons (ACS). Average exam scores were calculated, and the difference in the number of correct vs. incorrect answers between AI chatbots was evaluated using chi-square tests.

Results

GPT-3.5, Bard, and GPT-4 scored 86%, 70%, and 90% on the ABLS exam, respectively. GPT-3.5 and GPT-4 scored above the passing threshold (80%), as shown in Figure 1. No difference was found between GPT-3.5 and GPT-4 (p=0.538) and between GPT-3.5 and Bard (p=0.054), despite the borderline p-value. GPT-4 performed significantly better than Bard (p=0.012). There was no difference in LLM performance on clinical scenario questions, but GPT-4 was significantly better than Bard in answering direct questions (p=0.033).

Meanwhile, on the ATLS exams, GPT-3.5 scored an average of 65%, Bard scored an average of 61.7%, and GPT-4 scored an average of 83.3%. Only GPT-4 exceeded the passing threshold (75%), as shown in Figure 2. There was no significant difference in GPT-3.5 and Bard’s average scores (65.0% vs. 61.7%, p=0.59), but GPT-4 performed significantly better than both GPT-3.5 (83.3% vs. 65.0%, p=0.0012) and Bard (83.3% vs. 61.7%, p=0.0002). There was no significant difference in GPT-3.5, Bard, or GPT-4 performance on direct vs. clinical scenario question types.

Conclusions

The most recent and updated LLMs, such as GPT-4, have showcased a remarkable level of technical knowledge, to the extent of being able to successfully pass the ABLS and ATLS exams. With continued development, LLMs could become valuable resources for clinicians, enabling AI-augmented decision-making processes.

Applicability of Research to Practice

This study highlights the potential applicability of advanced language models like GPT-4 as valuable resources in the burns and trauma setting, particularly in the context of enhancing clinical decision-making processes through AI-augmented tools for healthcare professionals.
521 Assessing the Utility of Visceral Proteins as Markers of Nutrition
Authors: Taylor Billy Jay , Calder Sara , Shawe Isabella G , Islas Claudia , Richey Karen J , Foster Kevin N
Published: April 2024

Introduction

Burn injury leads to a profound catabolic state requiring aggressive nutritional support to facilitate healing, homeostasis, rehabilitation and to decrease infections. However, monitoring efficacy of nutritional support is difficult. Following the serum levels of visceral proteins is common practice, but recent studies have questioned the value of these tests in evaluating nutritional status. The purpose of this study was to examine the utility of visceral proteins as a measure of nutritional assessment and intervention.

Methods

This was a retrospective chart review of adult patients admitted over one year who required enteral feeding and had indirect calorimetry testing. Caloric data and associated visceral protein labs (pre-albumin, albumin, transferrin, and CRP) were collected during their enteral feeding duration. Patients were stratified by respiratory quotient (RQ), “Normal RQ” (RQ = 0.85-1.00) and “Low RQ” (RQ > 0.85), and Caloric % weekly intake, adequate intake (>90%) and inadequate intake (< 90%). Differences between groups were analyzed using a T-test or Wilcoxon rank sum test depending on data normality.

Results

A total of 44 patients met inclusion/exclusion criteria. Mean age was 50 years, mean TBSA was 27 %, mean BMI was 30.3. The majority were male 70% (n=31), mean length of stay was 58.5 days, mean ventilator days were 41 days. Mortality was 27% (n=12). There were no significant differences in visceral protein levels between RQ groups. There was no significant difference between % Caloric intake (adequate vs. inadequate) for the first 4 weeks. In the fifth week there were differences in pre-albumin, transferrin, and C-reactive protein levels between groups, with p-values of 0.02, 0.03, and 0.006, respectively. There was no significant difference in albumin levels at week 5. Analysis beyond 5 weeks was not conducted due to insufficient data.

Conclusions

Historically, visceral proteins such as albumin and pre-albumin have been used as nutrition markers. We now better understand that the albumin pool of the human body is comprised of little newly synthesized albumin, and protein intake has little effect on the value itself. Albumin and pre-albumin are negative acute-phase reactants and are greatly affected by the inflammation seen with burn injuries. We found no significant differences between pre-albumin and RQ. Conversely, there was also no significant difference between pre-albumin and those who were able to meet greater than 90% of their nutrition needs, and those who met less than 90% needs during weeks 1-4 of testing. There was a significant relation between all visceral proteins and caloric intake during week 5. This is likely explained by improved levels of CRP and overall decrease in inflammation.

Applicability of Research to Practice

Our results support that visceral proteins are not good indicators of nutrition status in burn patients, while in a state of inflammation.
525 Evaluating Adherence to a New Pre-Operative Enteral Feeding Guideline in a Single Burn Center
Authors: Marsh Molly , Cruz Aryn , Chrisco Lori , Hollowell Jamie L , Levine Ashley , Nizamani Rabia , King booker , Williams Felicia
Published: April 2024

Introduction

Malnutrition increases hospital length of stay, mortality, readmissions, overall costs, and also delays healing. Enteral nutrition via tube feeding (TF) is often used as primary or supplemental nutrition for burn patients. Our institution recently adopted a new policy to reduce TF hold times pre-operatively. An algorithm determining when TF are held pre-operatively to mitigate full body catabolism considers type of TF access (gastric or post-pyloric), the presence of a secure airway, and if the surgery involves the aerodigestive tract in order. We aimed to evaluate our compliance with the initiation of these new guidelines.

Methods

This was a single center, retrospective study using our institution’s electronic medical record (EHR) admission list for patients on the burn service. Inclusion criteria consisted of patients admitted from June 1 through September 26, 2023, >18 years of age, had >20% TBSA burns requiring operative intervention, and received TF pre-operatively for at least one of their surgeries. Data collection included burn diagnosis, operating room (OR) date and time, feeding access, if the patient would be prone, receiving aerodigestive surgery or extubated post operative, NPO time ordered versus NPO time desired per guidelines, if the feeding protocol was followed, the hours of missed nutrition based on the expected feeding times outlined in the new policy, the calculated loss of protein and energy, and the percent of estimated nutrition needs lost.

Results

There were 9 patients (n=9) who met the inclusion criteria and underwent a combined total of 14 surgeries. Out of the 14 operative days, the policy for the new NPO policy was only followed on one day (7.1%). These policy deviations led to an average of 6.7 missed hours of tube feed, 931 missed kilocalories, 60 grams of protein, 32.7% estimated energy needs, and 31.9% estimated protein needs per operative trip. All patients survived.

Conclusions

Missed opportunities for enteral nutrition led to significant morbidity for our patients. Despite global acceptance to this guideline, compliance was suboptimal and resulted in substantial loss in nutrient delivery for our patients. Further education, time to allow culture change to take effect, and a standardized EHR order set can contribute to the success of this guideline in the future.

Applicability of Research to Practice

This was one step of many to improve nutrient delivery to burn patients in our center and attenuate the risk and adverse effects of malnutrition for our patients. Reducing pauses in TF is a critical step in optimizing nutrient delivery for patients with high metabolic demands in order to improve outcomes.
533 Preliminary in Vivo and Atomic Force Microscopy Assessment of Uninjured Skin, Donor and Graft Sites
Authors: Pistek Apolline S , Burnett Lindsay , Gabriel Vincent , Bharadia Shyla K , Mukherjee Priyanka G , Amrein Mathias
Published: April 2024

Introduction

With limited dermal function at the recipient site, fibrosis is expected following split-thickness skin grafting. Additional hypertrophic scar may develop within the graft, along seams and margins or at the donor site. This study focuses on the mechanical changes in the skin following split-thickness skin grafting as assessed by a non-invasive negative pressure device and atomic force microscopy to describe gross and sub-cellular mechanical properties in the differing skin states post-grafting.

Methods

Participants with full-thickness burn injuries acutely managed with a split-thickness skin graft, closed donor and graft sites without any previous steroid injection or laser therapeutic interventions and a suitable control site were recruited. A negative pressure device was applied to grafted, donor, and uninjured contralateral control sites and response recorded to vacuum pressure and release to calculate Young’s elasticity modulus. A 4mm punch biopsy was harvested from each labelled site and immediately processed using atomic force microscopy using silicon cantilevers conjugated with a spherical glass tip (radius 2.5 μm;) in a custom 3D printed frame to determine Young’s elasticity based on the Hertz fit model (fig 1a-b).

Results

A total of 5 participants (3 male, mean age 32.4 range 21-54, 152-427 days post-injury) have been recruited for the study thus far. Measurements were taken on the thigh of 4 participants and on the abdomen of 1. Atomic force microscopy data demonstrates lowest Young’s elasticity modulus (mean 1.49 ± 0.12 kPa) at the control sites (fig 1b graft 3: x-axis frequency, y-axis YM) with highest Young’s elasticity modulus (mean 2.70 ± 0.10 kPa) at the grafted sites. The donor sites are in the middle of the graft and control, (mean 1.98 ± 0.88 kPa). This trend is in concordance with clinical observation and elasticity probe measurement, where the graft is the toughest and the donor and control are similar (fig 1c).

Conclusions

Initial elasticity measurement by a non-invasive vacuum device has been in agreement with atomic force microscopy assessment. Further sampling is required to verify preliminary results, simulate resting tension in the skin and assess change following intervention.

Applicability of Research to Practice

Valid and reliable non-invasive measures will be informative of treatment effectiveness. Sub-cellular assessment of mechanical changes in skin graft and scar may direct therapeutic interventions.
534 Retrospective Study Comparing Acute Healing Outcomes of Two Epidermal Skin Substitutes in Paediatric Partial-Thickness Burns
Authors: Khamise Ameer , Lapid Hadas , Mishra Ankit , Murray Alexandra M
Published: April 2024

Introduction

Paediatric burns are a significant global health issue; partial thickness (PT) wounds from scalds are a common injury pattern. Skin substitutes, such as collagen based (CB) dressings, are frequently used in managing these cases. We conducted a novel comparative study analysing the acute healing outcomes of a CB dressing and a novel biosynthetic cellulose (BC) dressing in paediatric PT burns.

Methods

All paediatric patients (age < 18) with PT burns that were managed with either the CB or the BC dressings over a four-year period at our paediatric burns centre were included. Data on adherence, infection, length of stay, complete healing time, acute follow-up time, and return to theatre were extracted and a statistical analysis performed.

Results

Of the 89 patients included, 28 received BC dressing and 61 received CB dressing. Mean Total Body Surface Area (TBSA) was 5.9% (range 1-15) and median age was 23 months (range 8-169). BC dressing had a higher adherence rate (85.7% vs 78.7%, P=0.767) and a lower infection rate (3.6% vs 16.4%, P=0.164) than CB dressing. These trends were preserved when superficial PT only and superficial and deep PT sub-groups were analysed. Healing and infection rates were unaffected by post-operative antibiotics in both groups (P=1 and P=0.803, respectively). Return to theatre for further surgery was required in 10.7% of the patients for BC and in 6.6% for CB dressing (P=0.507). Median time to complete healing was longer in BC (19.5 vs 16 days, P=0.279). BC dressing median hospitalisation length was 1 day compared to 2 days for CB dressing (P=0.706).

Conclusions

The findings demonstrate that acute healing outcomes with the BC dressing in paediatric PT burns are comparable to those with the CB dressing, establishing the BC dressing as a viable alternative given its advantages in cost and avoiding porcine components. However, further prospective studies are warranted to compare acute and long-term outcomes with these products.

Applicability of Research to Practice

The study will directly inform clinical decision making on the use of frequently applied epidermal skin substitutes when managing paediatric partial thickness burns.
559 Rates of Follow up in Massively Burn Injured Patients
Authors: Heard Jason , Valdez Jessica , Palmieri Tina L , Romanowski Kathleen S , Sen Soman , Greenhalgh David G
Published: April 2024

Introduction

As burn care continues to improve, large total body surface area (TBSA) burn survival will increase. These survivors require more extensive care than smaller burns and are at higher risk for wound/scar related complications. In previous studies follow up after burn injuries tended to be low, especially with burns that cover a smaller TBSA%. The low follow up compliance has been linked to socioeconomic factors such as housing insecurity and substance use. There are limited studies that evaluate socioeconomic factors that contribute to follow up attrition in massive burn patient populations We hypothesize that patients with massive burn injuries and housing insecurity and substance use will have lower rates of follow up.

Methods

After approval by our Institutional Review Board, a retrospective chart review study was performed in adult patients admitted from 2009-2019 with >50% TBSA burns. Patients were excluded if they died during hospitalization or were discharged with plan to follow up at another burn center. Data collected included demographics, injury characteristics, zip codes, insurance type/status, follow up visits and number/type of reconstructive surgeries. County level data was abstracted from data.census.gov which. Univariate and regression analyses were performed using R software.

Results

There were 155 patients that met the inclusion criteria, 72 patients survived to discharge, and 7 patients were discharged to another burn center leaving 65 patients in the final analysis. Mean TBSA of all patients was 63.5% and mean age was 35.6 years. Fifty-four patients (83.1%) attended at least one follow up after burn injury. The median number of follows up scheduled and attended were 4 and 3.5 (range: 1-135) respectively. On Univariate analysis female patients followed up longer than male patients (771 vs 131 days; p=0.007) and patients with housing insecurity were less likely to follow up at all (4 vs 0 visits; p=0.0009). On multivariate regression analysis for attending any clinic visit, larger TBSA burn was independently associated with follow up (OR 1.22, p=0.046) and housing insecurity was independently associated with not following up (OR 0.003, p=0.02).

Conclusions

Patients with large TBSA% burn injuries are a unique patient population and in theory should require more frequent follow up than patients with smaller TBSA burns. Data from our single center study showed patients that survived massive burn injuries did have reasonable one time follow up. However, certain patient populations should be targeted for closer follow up adherence, including patients facing housing insecurity, uninsured patients, and male patients.

Applicability of Research to Practice

This research can help other burn programs identify patients who may be vulnerable to have higher follow up attrition rates so that these specific patient populations can be followed closely after discharge.
560 Is the Need for Follow up Lost in Translation?
Authors: Epstein Larissa , Franco Carina , Coward Alexandra , Heard Jason , Sen Soman , Palmieri Tina L , Romanowski Kathleen S
Published: April 2024

Introduction

There is limited research evaluating patients of limited English proficiency (LEP) on outcomes after burn injury. Studies have shown that patients with LEP have reduced access to care, longer admissions, are more likely to be discharged to a nursing facility and are more likely to return to the emergency department (ED). Burns require significant inpatient and outpatient coordinated care for successful discharge planning and patient education regardless of language preference. This study examines the effect of LEP on outcomes following burn injury. We hypothesize that burn patients with LEP will have longer hospital stays, fewer follow up (F/U) visits, and more ED visits after discharge.

Methods

Following IRB approval, a retrospective chart review was conducted using electronic medical records for burn patients admitted from January 2018 to December 2019. Data collected includes patient demographics, burn injury, burn outcomes, preferred language, and F/U care. Analysis was conducted with SAS statistical software, version 9.4 (SAS Institute, Cary, NC, USA) using Chi-square, Fisher Exact, Spearman Correlation, Wilcoxon 2-sample and Kruskal-Wallis tests.

Results

A total of 760 patients with a median age of 46 years (Interquartile range (IQR) = 26) were analyzed. Median total body surface area (TBSA) burn was 6.5 (IQR = 12) and 15% had inhalation injury. The median length of stay (LOS) was 9 days (IQR = 18) and 38 patients (5%) died. Reviewing post-burn care, 613 patients (81%) scheduled F/U, 397 patients (52.7%) attended a F/U appointment within 30 days of discharge, 85 patients (11.2%) presented to the ED, and 46 patients (6.1%) were readmitted. Only 61 patients (8%) preferred a language other than English. Among patients with LEP, Spanish was the most spoken language (5.6%), followed by Hmong (0.92%). When patients with LEP were compared with English speakers there was no difference in age (42 (22) vs. 46 (26), p=0.67), TBSA (5.5 (10.5) vs. 6.6 (11.8), p=0.32), mortality (3.3% vs. 4.7%, p=1), LOS (8 (16) vs. 9 (18), p=0.43), ICU days (2 (16) vs. 3 (15), p=0.43), inhalation injury (13.1% vs. 14.9%, p=0.87), and discharge to home (86.9% vs. 75.9%, p=0.44). Patients with LEP were more likely to have follow up scheduled at discharge (93.4% vs. 80.2%, p=0.04), attend F/U (78.7% vs. 50.7%, p=0.0005), and present to the ED after discharge (19.7% vs. 10.5%, p=0.03). There was a trend towards them being readmitted more than native English speakers (11.5% vs. 5.6%, p=0.08).

Conclusions

Patients with LEP were no different from their English-speaking counterpart with respect to traditional outcome measures (LOS or mortality) but had increased healthcare utilization (F/U or return to the ED).

Applicability of Research to Practice

As the number of patients with LEP increases, health care providers must be aware of the influence this has on outcomes following burn.
567 Distance to Burn Center Is Not Associated with Long-term Psychologic Outcomes Following Burn Injury
Authors: Dye Crystal , Risinger William B , Thompson Spencer , Keeven David , Smith Jason , Bozeman Matthew
Published: April 2024

Introduction

Burn injury predisposes patients to significant psychologic morbidity including anxiety and depression. Adding to the burden of injury, patients often require transfer to specialized burn centers located far from home, family, and friends. We sought to assess the impact of distance to burn center on long-term psychologic outcomes.

Methods

Patients admitted to our American Burn Association verified center from January 2021- June 2023 were identified. Demographics, burn characteristics, and follow up anxiety (Generalized Anxiety Disorder-7) and depression (Patient Health Questionnarie-2) screening scores were reviewed. Distance to burn center (miles) was determined based on patient’s home address. Wilcoxson rank-sum, chi-squared, and logistic regression tests were used to identify variables associated with post-burn anxiety. Linear regression was used to evaluate the relationship between distance to burn center and GAD-7 scores.

Results

Of the 267patients identified, 35.6% and 27.9% screened positive for anxiety (GAD-7 > 10) and depression (PHQ-2 > 3) respectively at follow-up. On univariate analysis, female sex (38% vs. 21%, p < 0.01), morphine milligram equivalents (MME) on the last day of hospitalization (30 vs. 22.5, p=0.02), prior psychiatric history (37% vs. 13%, p< 0.01), and inhalation injury (9% vs. 3%, p=0.05) were associated with positive anxiety screens. Distance to burn center was similar between patients with positive and negative anxiety screens (40 vs. 47 miles, p=0.49). Via logistic regression, MME on the last day of hospitalization (OR: 1.02, p=0.03) and a history of psychiatric illness (OR: 3.93, p < 0.01) all predicted post-injury anxiety when accounting for age, %TBSA, burn mechanism, sex, injury at workplace, inhalation injury, and hand/face involvement. Distance to burn center showed no linear relationship to GAD-7 scores (β = -0.004, R2=0.00, p=0.64).

Conclusions

Distance to burn center is not associated with increased long-term psychologic outcomes following burn injury, further supporting the transfer of patients to specialized burn centers. However, prior history of psychiatric illness and increased utilization of inpatient narcotics are all associated with increased probability of long-term anxiety.

Applicability of Research to Practice

Provides further evidence for the transfer of burn patients to specialized centers.
568 Clinician Survey on Emotional Challenges in Treating Self-Immolation or Self-Inflicted Burn Patients
Authors: Honea Ashley E , Richey Karen J , Foster Kevin N
Published: April 2024

Introduction

Self-immolation (SIM) is an uncommon method of attempted suicide involving flammable substances, with suicidal intent. By contrast self-inflicted (SIF) burn injuries utilize a chemical or heated object to cause injury, without suicidal intent. Caring for either patient population can have emotional and ethical challenges. The purpose of this study was to better understand the perspectives and experiences of the healthcare clinician when caring for these patients and identify the need for enhanced support.

Methods

An 11-item survey was distributed to burn center professionals via SurveyMonkey. Questions were developed to seek healthcare professionals’ attitudes, emotional and ethical challenges in treating these patient populations. Respondents were stratified into two groups, those that responded yes to having found it emotionally challenging to care for this patient population (Y) and those that responded no (N).

Results

A total of 65 individuals responded to the survey, and 58 surveys were fully completed. The majority, 65%, of respondents were between ages 22-39, (n=41). Most were burn nurses, 46.7% (n = 29), followed by rehabilitation professionals (rehab), 12.9% (n = 8), advanced practice practitioners (APP), 9.6% (n=6) and physicians 8% (n=5). When stratified, 53% (n=31) responded yes (Y) when asked if they found it emotionally challenging to care for this patient population and 48% (n=28) responded no (N). There were no significant differences between groups for age, gender, years in profession or years in burn care. When examined by profession, 75% of rehab, 67% of psychosocial, 50% of nurses, 40% of physicians and 33% of APP respondents answered yes that care of this population was emotionally challenging. The majority of both groups responded that they received support from team members. When asked if care of these patients created an ethical or moral dilemma 42% of Y and 25% of N responded yes. Y were more likely to have experienced a change in their own mental health 52% vs 7% N. When asked if same day support would be helpful 74% (n=23) of Y and 42% (n=12) responded yes. The preferred format for help was 1:1 or group.

Conclusions

The majority of staff reported emotional and/or ethical challenges when caring for this population created. Of those who responded that care of these patients was not emotionally challenging, interestingly, 25% experienced ethical or moral dilemmas and 43% felt that having same day support would be beneficial. Identification of the need for enhanced support for staff in the hospital setting is critical to avoid burnout, secondary traumatic stress and compassion fatigue for healthcare professionals.

Applicability of Research to Practice

This study highlights the need for a specialized in-house enhanced support program for burn professionals to address their emotional and mental well-being.