bluuebunny/crossref_metadata_2025 huggingface dataset:
83 The Impact of Tracheostomy on Long-term Patient Outcomes: A Burn Model System National Database Study
Authors: Galicia Kevin E , Kubasiak John , Mehta Anupama , Kowalske Karen J , Gibran Nicole S , Stewart Barclay T , Wolf Steven E , Ryan Colleen M , Schneider Jeffrey C
Published: March 2022

Introduction

Management of the upper airway is crucial to burn care, especially in the setting of inhalation injury or burns to the face or neck. Endotracheal intubation is often performed to secure the airway; however, tracheostomy may be necessary in patients requiring prolonged ventilatory support. This study compares long-term outcomes of burn patients with and without tracheostomy.

Methods

Data from the Burn Model System National Database, collected from 2013 to 2020, were analyzed. Demographic and clinical data were compared between those with and without tracheostomy. The following patient-reported outcome measures, collected at 6-, 12-, and 24-months, were analyzed: Veterans Rand 12 Physical Component Summary Score (VR-12 PCS), Veterans Rand 12 Mental Component Summary Score (VR-12 MCS), Satisfaction with Life (SWL), Community Integration Questionnaire (CIQ), Patient-Reported Outcomes Measurement Information System (PROMIS-29), employment status, and number of days to return to work. Regression models were used to assess the impact of tracheostomy status on long-term outcome measures, controlling for demographic and clinical variables.

Results

Of the 714 patients included in this study, 39 (5.46%) received a tracheostomy and 675 (94.54%) did not. The two groups were similar across all demographic data collected. Tracheostomy patients were more likely to have flame injury, inhalation injury, larger burn size, more trips to the operating room, longer hospital stay, and greater number of days on a ventilator (p< 0.001). Regression model analyses demonstrated that tracheostomy was associated with worse VR-12 PCS scores at 6-, 12-, and 24-months (6.6 [95% CI 1.5, 11.8], p=0.012; 11.5 [6.2, 16.8], p< 0.001; 10.8 [4.2, 17.5], p=0.001). Tracheostomy was also associated with worse scores in two PROMIS-29 domains, physical function and pain interference. For physical function, the association was seen at 6-, 12-, and 24-months (7.4 [3.0, 11.8], p=0.001; 9.6 [5.2, 14.0], p< 0.001; 11.3 [5.8, 16.9], p< 0.001). For pain interference, the association was only seen at 12-months (-5.3 [-10.0, -0.55], p=0.029).

Conclusions

After burn injury, patient-reported outcome measures of physical function and pain interference were significantly worse with tracheostomy.
86 Outcomes for 43 Hand Burns Treated with 2:1 Meshed and Epidermal Autografts with Abundant Donors
Authors: Yoo Daniel , Taylor IV Malcolm M , Barnett Scott , Tuggle Charles T , Kopari Nicole , Carter Jeffrey E , Phelan Herb A
Published: March 2022

Introduction

Our group has previously reported our experience in treating hand burns with 2:1 meshed autografting and simultaneous application of autologous skin cell suspension (ASCS) even when donor sites are abundant. Here, we sought to expand on this experience. We hypothesized that the use of 2:1 meshed autografting and ASCS (MA/ASCS) would provide comparable outcomes to hand burns treated with sheet graft.

Methods

A retrospective review was conducted of all subjects operated on for deep 2nd and 3rd degree hand burns at our ABA-verified burn center from April, 2018 to May, 2021. Exclusion criterion was a burn of >20% TBSA. The cohorts were those subjects treated with MA/ASCS versus those treated with split thickness sheet, pie-crust, or 1:1 meshed autograft alone (STAG). Outcomes included proportion returning to work (RTW), length of time for RTW, and time to wound closure. Mann-Whitney U test was used for comparisons of continuous variables, and Fishers Exact test for categorical variables. Values are reported as median and interquartile range.

Results

Sixty-eight subjects fit the study criteria (MA/ASCS n=43, STAG n=25). The MA/ASCS group was significantly older than the STAG cohort (45.5 yrs [32, 59.25] vs 35 [28, 45], p=0.013) with larger %TBSA burns overall (11.5% [7, 16.25] vs 2% [1, 3], p < 0.0001), and larger hand burns (186 cm2 [124.75, 330.5] vs 104 cm2 [56, 164], p=0.001). Comparable results were seen between MA/ASCS and STAG, respectively, for time to wound closure (8 days [7, 13] vs 8 [6, 14], p=0.48), proportion RTW (51% vs 64%, p=0.33), and days for RTW among those returning (38 [29.25, 62.75] vs 34.5 [20.75, 57], p=0.471). Fractional ablations were performed in 14% of the MA/ASCS group and 12% of the STAG group.

Conclusions

Despite being significantly older, having larger hand wounds, and larger overall wounds within the parameters of the study criteria, patients with 20% TBSA burns or smaller whose hand burns were treated with 2:1 mesh and ASCS overspray had comparable time to wound closure and return to work as subjects treated with 1:1, pie-crust, or sheet STAG.
93 Foot Burns in Persons with Diabetes outcomes from the National Trauma Data Bank
Authors: Perrault David , Cobert Jason , Gadiraju Veda , Gurtner Geoffrey , Pham Tam N , Sheckter Clifford C
Published: March 2022

Introduction

Diabetes Mellitus (DM) is an epidemic in the US that complicates the treatment of burn injuries. Lower extremity burns in diabetic patients, particularly the feet, are challenging problems with predictably unfavorable outcomes, as demonstrated by single-institution studies. National evaluations are absent, especially with regard to limb salvage. We aim to characterize lower extremity burns in persons with DM and evaluate the likelihood of amputation. We hypothesize that the incidence of DM associated foot burns is increasing in the US, and these patients are more likely to undergo lower extremity amputation than those without DM.

Methods

The National Trauma Data Bank (NTDB) was queried from 2007-2015 extracting encounters with primary burn injuries of the feet using International Classification of Diseases (ICD) 9th Edition codes. DM is a predefined comorbidity within the NTDB, allowing for cohort comparisons. Logistic regression modeled predictors of lower extremity amputation. Patient covariables included age, sex, race/ethnicity, and comorbidities. Burn covariables included % burn total body surface area (TBSA), mechanism, and region of burn center. Poisson regression evaluated for significance in temporal changes in DM foot burns.

Results

There were 116,796 adult burn encounters of which 7,963 (7%) had foot burns. Of this group, 1,308 (16%) had DM. DM foot burn encounters were older, more likely to be male, and had more comorbidities than non-DM foot burn encounters (all p< 0.001). DM foot burn encounters were more likely to sustain a scald injury (compared to flame) and had smaller %TBSA (all p< 0.001). Additionally, 5.6% of encounters with DM foot burns underwent amputation compared to 1.5% of non-DM encounters (p< 0.001). Independent predictors of lower extremity amputation included DM (OR 3.70, 95% CI 2.98 – 4.59), alcohol use, smoking, chronic kidney disease, burn size >20%, African American/Black race, male sex, and age >40 years (all p< 0.01). The incidence of DM foot burns increased over the study period with an incidence rate ratio (IRR) of 1.09 (95% CI 1.07 – 1.12, p< 0.001).

Conclusions

In the largest cohort study to date, DM was associated with nearly a 4-fold increase in amputation after adjusting for available confounders. Furthermore, the incidence of DM foot burns is increasing. Strategies for optimizing care in persons with DM foot burns are need to improve limb salvage.
95 Incidence of Hypertrophic Scar Diagnosis in Burn Patients Prescribed Glucocorticoids
Authors: Joglar Alejandro A , Golovko George , Chokshi Shivan N , Efejuku Tsola A , Wermine Kendall , Gotewal Sunny , De La Tejera Giovanna , Villarreal Elvia L , Corona Kassandra K , Keys Phillip H , Song Juquan , Wolf Steven E , El Ayadi Amina
Published: March 2022

Introduction

Despite advancements in burn care, the optimal treatment to prevent or treat hypertrophic scars is still elusive. Therefore, the objective of this study is to compare the efficacy of five glucocorticoid medications commonly used in the treatment of hypertrophic scarring in burned patients using a large patient database.

Methods

Patients diagnosed with hypertrophic scarring, hypertrophic disorders of the skin, or scar conditions and fibrosis of skin at least one day after burn injury were identified in the TriNetX database. Hydrocortisone, methylprednisolone, dexamethasone, triamcinolone, and prednisone were the glucocorticoids investigated. Those who received a glucocorticoid on the same day or any time after the incidence of burn injury were compared to those who did not take glucocorticoids in the previous five years. Patients were stratified into four groups based on percent total body surface area (TBSA) burned: 0-9%, 10-19%, 20-39%, and 40-100%. A total of 165,041 burned patients were found who did not receive glucocorticoids, and 66,652 burn patients who received glucocorticoids after injury. Statistical analysis for comparison included a risk ratio with a significance defined as a p-value < 0.05.

Results

In all burn patients identified, the risk of hypertrophic scarring diagnosis was reduced with methylprednisolone (RR=0.60, p< 0.001) and prednisone (RR=0.37, p< 0.001), while it was increased with dexamethasone (RR=2.48, p< 0.001). Stratification based on %TBSA burned showed that diagnosis of hypertrophic scarring was reduced in the < 10% TBSA group with methylprednisolone (RR=0.49, p< 0.001) and prednisone (RR=0.33, p< 0.001), while it was increased with dexamethasone (RR=3.6, p< 0.001). Similarly, in the 10-19% TBSA group, the risk was reduced with prednisone (RR=0.57, p=0.024) while increased with dexamethasone (RR=2.2, p< 0.001). No significant effect was observed with hydrocortisone or triamcinolone with any of the %TBSA groups examined. Patients treated with dexamethasone continued to show increased risk for hypertrophic scar diagnosis with 20-39% TBSA (RR=1.69, p< 0.001) and 40-100% TBSA (RR=1.87, p< 0.001).

Conclusions

While methylprednisolone and prednisone decreased the risk of hypertrophic scarring diagnosis among all burn patients identified, dexamethasone showed an increased risk of hypertrophic scarring diagnosis in all burn patients and in each %TBSA stratified group.
96 Poly-dl-lactide Copolymer-dressing Use on Burn Wounds and Skin Graft Donor Sites - An Institutional Review
Authors: Lagziel Tomer , Metoyer Garyn , Kawaji Qingwen , Akhavan Arya A , Cox Carrie A , Caffrey Julie , Hultman Charles S , Duraes Eliana F
Published: March 2022

Introduction

In burn surgical care, wound coverage and the corresponding dressing are paired to maximize the ability to promote re-epithelization, minimize pain and patient discomfort, dressing change frequency and overall cost. This dressing, a copolymer material based on DL lactic acid, has been described as a reliable alternative dressing for partial thickness burns as well as skin graft donor sites with comparable wound-healing quality and duration. Our aim is to assess outcomes results of this copolymer dressing at our institution, as applied to partial thickness burn wounds and graft donor sites.

Methods

We performed a retrospective analysis of 55 adult patients admitted between January 1, 2020 to August 25, 2021 for the treatment of partial thickness burns that were managed with a poly-DL-lactide copolymer skin substitute at the burn wound and/or autograft donor site. Three study groups were established based on application site: wound only (group 1), donor site only (group 2), and both (group 3). We assessed operative times, infections rates, complications, length of stay, readmission rates, and mortality.

Results

Preliminary data of 40 patients shows clinically similar results for analgesic requirements, operative length, and hospital LOS between group 1 and group 3. Group 2 showed higher analgesic requirements, lower operative times, a lower LOS, and lower readmission rates. Group 3 shows higher pain levels and longer operative times, when compared with groups 1 and 2, but lower readmission rates than group 1.

Conclusions

The poly-DL-lactide copolymer skin substitute offers reliable wound coverage for a partial thickness burns while also reducing frequency of dressing changes and associated pain correlating to reduced length of hospital stay and wound healing interval.
98 Plasma Extracellular Vesicles Released After Sever Burn Injury Modulate Macrophage Function
Authors: Willis Micah L , Mahung Cressida , Wallet Shannon , Coleman Leon , Maile Robert
Published: March 2022

Introduction

Extracellular microvesicles (MVs) have emerged as key regulators of immune function across multiple diseases and potential biomarkers. Severe burn injury is a devastating trauma with significant immune dysfunction that results in an ~12% mortality rate due to sepsis-induced organ failure, pneumonia, and other infections. Severe burn causes a biphasic immune response: an early (0-72 hrs) hyper-inflammatory state, with release of pro-inflammatory damage-associated molecular pattern molecules (DAMPs), such as HMGB1, and cytokines (e.g.IL-1b), followed by an immunosuppressive state (1-2 weeks post injury), associated with increased susceptibility to life-threatening infections. We have reported that early after severe burn injury HMGB1 and IL-1b are enriched in plasma microvesicles (MVs), suggesting a role for MVs in post-burn immune activation. Here we tested the impact of MVs isolated after burn injury on phenotypic and functional consequences in vivo and in vitro using adoptive MV transfers.

Methods

We then assessed if the cargo of MVs following burn injury in humans could predict length of hospital stay. MVs isolated early from mice that underwent a 20% total body surface area (TBSA) burn injury (burn MVs) caused similar cytokine responses in naïve mice to those seen in burned mice early after injury. Burn MVs transferred to RAW264.7 macrophages caused similar functional (i.e. cytokine secretion) and genetic changes (measured by NanoStringTM) seen with their associated phase of post-burn immune dysfunction.

Results

Burn MVs isolated early (24h) induced MCP-1, IL-12p70 and IFNg, while MVs isolated later (1 and 2 weeks) blunted RAW proinflammatory responses to bacterial endotoxin (LPS). Unbiased LC-MS / MS proteomic analysis of early EVS (< 72 h post-injury) showed similarities in human and mice.

Conclusions

In our sample of large burn injury, EV SAA1 and CRP correlated with TBSA injury in both sexes and were correlated with length of hospital stay in women.
100 Burn Causes Aberrant Macrophage Polarity Conversion in Skeletal Muscles, Which Is Mitigated by Auto/mitophagy-targeted Therapy
Authors: Sugawara Yoh , Khan Mohammed A , Morinaga Hiroyuki , Martyn Jeevendra , Yasuhara Shingo
Published: March 2022

Introduction

Major burn injury (BI) is associated with excessive inflammation. We have reported autophagy/mitophagy response defect in skeletal muscles in BI, leading to diminished homeostasis capability of cells and mitochondria. Macrophages play central roles in the process of wound healing, from causing inflammation, clearing cell debris, to coordinating tissue repair. Classically, M1 macrophages are considered as pro-inflammatory phenotype, and M2 as anti-inflammatory/pro-regeneration phenotype, though complexity of constituent of macrophage subpopulations, being increasingly recognized. The relationship between BI-induced autophagy/mitophagy defect and the regulation of macrophage polarity in BI has not been studied so far.

Methods

Body trunk BI covering 30% of body surface area or sham-bun (SB) treatment was administered to wild type mice. At post burn day (PBD) 5, mechanical injury was created in sternomastoid muscles (STM) by pressure injection of saline into the tissue ( >3x fracture toughness) to study effect of BI on the wound healing process in muscles. STMs were harvested at post surgical day (PSD)1, 3, 7 and 14, and cryosectioned for immunohistochemistry against satellite cells (pax7), and macrophages (CD86 for M1, CD206 for M2, and F4/80 for general). As a therapeutic approach, we tested the effect of auto/mitophagy modulating drug, trehalose, whose pro-auto/mitophagy effect has been attributed to mitigation of the blocked flux of auto/mitophagy (due to BI) in our separate studies.

Results

SB control group showed both total and M1 macrophage numbers chronologically decreasing from PDS1 towards PSD14. BI caused delay in the subsiding of the macrophage infiltration. The greater majority of the macrophage in BI was CD86 (+) M1 phenotype, confirming the pro-inflammatory traits in BI (+46.4% of SB at PSD7). Contrarily, CD206 (+) M2 macrophage started from low numbers at PSD1 and increased towards PSD7 and 14 in SB. In BI, however, M1/M2 conversion was markedly delayed (-59% of SB at PSD7), which was mitigated by trehalose (+134% of BI at PSD7). Pax7 (+) muscle satellite cells increased from PSD1 towards PSD14 in SB, but the response was prominently defective in BI, and was normalized by trehalose.

Conclusions

M1 to M2 conversion observed in SB was defective in BI with concomitant defect in satellite cell proliferation. Autophagy/mitophagy treatment drug, trehalose mitigated the phenotype conversion defect in macrophage.
102 Vaping of Vitamin E Acetate Causes Acute Lung Injury in a Dose-dependent Manner in Sheep
Authors: Homma Kento , Hashimoto Kazuki , Bazhanov Nikolay , Salsbury John , Traber Maret G , Enkhbaatar Perenlei
Published: March 2022

Introduction

The Centers for Disease Control and Prevention and the Food and Drug Administration have reported an increasing number of clinical cases of pulmonary injury following the use of e-cigarette/vaping products. Although the causative factors for the national outbreak of electronic-cigarette, or vaping product use-associated lung injury (EVALI) has not been established, CDC reported that vitamin E acetate (VEA) is strongly linked to the EVALI outbreak. In this study, we tested the hypothesis that VEA vaping causes acute lung injury in a dose-dependent manner in a sheep model.

Methods

Sheep were surgically prepared under anesthesia and analgesia with multiple vascular catheters (pulmonary arterial, left atrial, and femoral arterial). To assess pulmonary edema, the mediastinal lymph node vessel draining the lung was cannulated. After a 5-day surgical recovery, a tracheostomy tube and urinary catheter were placed. Then, the sheep were placed on a mechanical ventilator and VEA vaping was immediately started in the following groups: (1) vaped with glycerol (n=1); (2) vaped with 0.4mg of VEA (n=2); (3) vaped with 0.6mg of VEA (n=1); (4) vaped with 0.8mg of VEA (n=7); and (5) not injured, not treated (Sham, n=6). Sheep were resuscitated with lactated Ringer’s solution (4mL/kg/hr). Sheep in a conscious state was monitored with 4 hrs intervals for cardiopulmonary variables for 48 hrs.

Results

Pulmonary gas exchange, represented by the PaO2/FiO2 ratio, was unchanged in sham, glycerol, and 0.4 mg VEA groups. In the 0.6 VEA group, the PaO2/FiO2 ratio was decreased from 42 to 48 hrs, while in the 0.8 mg VEA group, it was strongly decreased starting at 24 hrs and remained low throughout the remaining period. Lung lymph flow, an index of pulmonary microvascular permeability, was increased more than 2-fold in 0.6 and 0.8 mg VEA groups. Lung compliance also tended to decrease in all VEA groups.

Conclusions

VEA vaping causes acute lung injury in a dose-dependent manner in sheep. Further studies should investigate underlying mechanistic aspects that cause increased microvascular permeability.
114 Long Term Impact of Hospital Acquired Multi-drug Resistant Organisms on Health-related Quality of Life
Authors: Ashford Nathaniel K , Oh Jamie , McMullen Kara , Carrougher Gretchen J , Hickey Sean A , Ryan Colleen M , Schneider Jeffrey C , Gibran Nicole S , Stewart Barclay T
Published: March 2022

Introduction

MDROs colonize wounds and cause infections for hospitalized burn patients, which may lead to increased infection risk, wound complications, longer (LOS) and more cost. Little is known about the long-term impacts of MDRO colonization and infection on burn survivors. We aimed to describe the impacts of colonization on long-term health-related quality of life (HRQoL), itch, and pain.

Methods

Data from adult participants in a multicenter longitudinal outcome study were used. Data was described and χ 2 and Kruskal-Wallis testing was applied to determine differences between the two groups. Outcomes included Veterans RAND 12 (VR-12) physical component summary score (PCS), and PROMIS 29 domains for pain intensity, fatigue, pain interference, physical function, and sleep disturbance. Pruritus was assessed using the 4-D Itch scale for total itch. Multilevel, multiple linear regressions were used for outcome measures at 6 m post-injury. Random effects regression with robust standard errors (SE) were used to evaluate the impacts over time.

Results

The study included 704 individuals and 92 were MDRO colonized (13%). Colonized patients had larger burns (25% TBSA, IQR 9-45 vs. 8% TBSA, IQR 3–20; p < .001), more operations (4, IQR 2-7 vs. 1, IQR 1-3; p < .001), more grafting (17% TBSA, IQR 3-46 vs. 3% TBSA, IQR 1- 9; p < .001), more ventilator days (2, IQR 0–8 vs. 0 IQR 0-0; p < .001), and longer LOS (34 days, IQR 17 – 64 vs. 16, IQR 9 - 27; p < .001). Adjusting for confounding covariables, such as demographics, colonization was associated with a lower PCS score (OR -0.33, 95% CI -0.68, -0.06; p=.018); a higher fatigue score (OR 0.46, 95% CI 0.13, 0.79; p = .007) and worse itch (OR 0.4, 95% CI -0.01, 0.75; p = .036). There was no association with pain intensity, pain interference, or sleep disturbance. Random effects regression indicated that colonization was associated with lower PCS (OR -5.0, 95% CI -8.60, -1.39; p = .007).

Conclusions

Impact of colonization extends beyond the immediate hospitalization and likely has long-term effects on HRQoL. Given our observation of lower physical function after MDRO, more granular research on taxa-specific effects, timing of colonization, and interventions are indicated to elucidate the impact on HRQoL.
120 The Association of Admission Cultures with Burn Outcomes
Authors: Baird Maree , Wall Joyce E , Man Angela , Allabadi Najib M , Jeschke Marc G , Savetamal Alisa , Schulz John T , Skipton Romanowski Kathleen S
Published: March 2022

Introduction

Burn patients are susceptible to infections. It is thought that burn wounds are initially sterile and become colonized by commensal and environmental microorganisms. Many burn centers have protocols to routinely screen patients for infection on admission. The ability of culture results to predict outcomes in burn patients has not been examined. In this study, we aim to examine the relationship between admission cultures and burn outcomes. We hypothesize that patients who have positive cultures on admission will have increased mortality and length of stay (LOS).

Methods

A retrospective chart review was conducted using electronic medical records for all adult patients admitted to three ABA verified burn centers from January 2016 -December 2017. Data collected included patient demographics, burn injury, burn outcomes, and cultures obtained within the first 24 hours of admission. Data analysis was conducted using Chi-square, Fisher Exact, Spearman Correlation, Wilcoxon 2-sample, and Kruskal-Wallis tests.

Results

A total of 1615 patients (mean age 45.87±17.65 years, 1145 males [70.9%]) were analyzed. Mean total body surface area burn (TBSA) was 9.6±14.2% and 10% had inhalation injuries. In this study population, the median LOS was 7 days (Interquartile range [IQR] = 12) and 72 patients (4.5%) expired. Older patients (p < .0001), those with higher scores on the 11-factor modified frailty index (mFI-11) (p < 0.0001), a higher TBSA (p< .0.0001) and inhalation injury (p < 0.0001) had a higher mortality rate. In examining the effect of admission cultures on mortality, there was no significant difference in mortality based on wound culture (p 0.14), Clostridium difficile (C. diff) (p 0.25), or urine culture (p=0.79) results. Patients with positive Methicillin-Resistant Staphylococcus Aureus (MRSA) screening (p 0.04) and those with positive blood cultures (p 0.01) were more likely to die from their injuries. Older patients (r= 0.14, p < 0.0001), those with a larger TBSA (r=0.49, p < 0.0001), and a higher MFI-11 score (r=0.12, p < 0.0001) had and increased LOS.. There was no association between LOS and positive wound cultures (p 0.08), or blood cultures (p 0.49) upon admission. Patients with positive MRSA results (p 0.003) and urine cultures (p 0.01) upon admission had a longer LOS while those with positive C. diff results had a shorter LOS (p 0.01).

Conclusions

Mortality is associated with standard predictors of outcomes (age, burn size, inhalation injuries, frailty scores) and positive MRSA screens and blood cultures. Patients with larger burns (define larger burn-maybe use the degree scale), a positive MRSA and negative C. diff had a longer LOS. Based on these results, cultures should be considered in all patients upon admission to the hospital as they are predictive of burn outcomes.
125 Community Socioeconomic Status Is Associated with Social Participation Outcomes
Authors: Kelter Brian M , Shepler Lauren J , Ni Pengsheng , Kazis Lewis E , Stewart Barclay T , Ryan Colleen M , Schneider Jeffrey C
Published: March 2022

Introduction

Socioeconomic factors are recognized as important social determinants of health. Data however are sparse describing the relationship between socioeconomic status and long term burn outcomes. This study aims to examine associations between community-level socioeconomic status and social participation outcomes in burn survivors.

Methods

Data was obtained from the Life Impact Burn Recovery Evaluation (LIBRE) Journey study that assesses longitudinal social participation outcomes of community dwelling burn survivors. Subjects were linked to the Distressed Communities Index (DCI), which combines seven indicators into a metric that depicts community economic well-being. Participants were categorized by time since burn (< 5, 5-15, ≥15 years). Linear regression models examined associations between DCI (zip code and county levels) and LIBRE domain scores (Family & Friends, Social Interactions, Social Activities, Work & Employment).

Results

The study included 314 burn survivors, (mean age 44.1 years; 61.0% female; 48.6% married; 82.8% white). The population was distributed among the time since injury categories (< 5: 35.8%, 5-15: 27.5%, ≥15: 36.7%). Approximately 18% of subjects were categorized in the “at risk” or “distressed” DCI categories. For survivors less than five years from burn, a DCI score increase of 1 standard deviation (worse socioeconomic status) at the zip code level was associated with decreased Family & Friends and Social Activity scores of 2.6 (p=.01) and 2.0 points (p=0.04), respectively (small effect sizes). This relationship was even stronger when controlling for sociodemographic factors. In regression analysis, survivors within the first five years from injury living in “at risk” or “distressed” communities showed worse Family & Friend scores by 6.5 points compared to those living in “prosperous” communities, even after adjusting for age, gender, race, ethnicity, education, and marital status (p=0.04; moderate effect size). There were no significant associations between DCI and LIBRE domain scores for survivors assessed beyond 5 years from injury.

Conclusions

Social participation outcomes were worse in burn survivors who lived in socioeconomically disadvantaged neighborhoods. Burn survivors who face socioeconomic challenges may need additional support to address social disparities to improve outcomes.
525 Dysphagia in Thermal Injury: The Impact of Inhalation Injury on Incidence and Recovery
Authors: Weiner Bailey , Halfacre Harper , Lee Jenny , Harvin John A
Published: March 2022

Introduction

Dysphagia is known to be a prevalent condition in the burn population. Dysphagia can lead to adverse events such as aspiration pneumonia, dehydration, and malnutrition. However, there is little data on the incidence and duration of dysphagia specifically in the inhalation injury subset of burn patients. The aim of this study is to determine the incidence and factors that contribute to dysphagia in the inhalation injury burn population as compared to the cutaneous burn population.

Methods

A retrospective study was conducted of patients admitted to a burn center from January 2016 - January 2021 and intubated for >48 hours. Patients who died during hospitalization or transferred hospitals were excluded. Dysphagia duration was analyzed based on days free from the ventilator. Two groups were compared: 1) non-inhalational injury vs inhalational injury patients and 2) Grade 1 vs Grade ≥2 inhalational injury patients. Statistical analysis included student’s t-test, chi-square test, and Kruskal-Wallis test. Bayesian generalized linear models were created to measure the independent association of inhalational injuries with the outcomes.

Results

During the study period, 142 patients were admitted, of whom 49 patients had inhalation injury (35%). Inhalational injury patients had a lower %TBSA burn than non-inhalational injury patients (mean 18% ± 21% vs 31% ± 15%, p< 0.001). There were no significant differences in age, sex, tracheostomy placement, ventilator days, or hospital length of stay between the two groups. The inhalational injury group had a higher rate of dysphagia at the first Speech Language Pathologist (SLP) instrumental assessment (88% versus 51%, p< 0.001) and at discharge (55% versus 28%, p=0.001). After controlling for %TBSA, inhalational injury was independently associated with an increased odds of dysphagia at first SLP instrumental assessment (OR 13.0, 95% CrI 4.7-43.4, posterior probability ≥99%) and at discharge (OR 3.2, 95% CrI 1.5-6.9, posterior probability ≥99%). Additionally, inhalational injury patients had a longer period of dysphagia post-extubation with an average of 9.5 vs 7.1 days to any diet (p< 0.006) and average of 12.6 vs 7 days to a regular texture diet (p < 0.001). Grade 1 inhalational injuries had no difference in duration of dysphagia or dysphagia at discharge compared to Grade ≥2 inhalational injury patients.

Conclusions

Inhalational injury was independently associated with dysphagia upon initial SLP instrumental assessment and at discharge. Patients with an inhalational injury also had a longer dysphagia resolution time. The severity of the inhalation injury did not impact dysphagia incidence.
527 Practical Use of Biomarkers During Nutritional Support of Pediatric Burn Patients
Authors: Shiel Jennifer , Prelack Kathy
Published: March 2022

Introduction

Current guidelines for evaluating nutritional risk in acutely ill patients incorporate the assessment of inflammation and disease burden. Inclusion of laboratory measures such as C-reactive protein (CRP) in screening criteria used to identify nutritional risk has gained credibility. Other biomarkers influenced by inflammation include visceral proteins albumin (ALB) and pre-albumin (PAB). While visceral proteins are not valid indicators of nutritional status, they may be indicators of nutritional risk, which could potentially lead to poor clinical outcome. The purpose of this study is to evaluate if PAB, ALB, CRP, are useful markers for predicting clinical outcomes in children with severe burn injury.

Methods

As part of our quality assurance program, we collect data on all nutrition support interventions, monitoring and outcome in children admitted to our hospital with significant burn injuries. This analysis describes data collected from 2006-2019 in children who had a burn injury and received nutritional support for five days or greater. Data elements collected include general demographics, weekly measures PAB, CRP, ALB; length of stay (LOS), number of intensive care unit (ICU) days, days to wound closure, and days on nutrition support. Biomarkers PAB, ALB, CRP and burn size (as an indicator of disease burden) were entered into a multiple regression model using a stepwise procedure for each dependent outcome variables (LOS, ICU LOS, Days to Wound Closure, and Days on Nutrition Support).

Results

A total of 182 patients, 7.0 ± 5.0 years of age with 41.1 ±16.9 % total body surface area (TBSA) burns were included in the analysis. TBSA, mean CRP and mean PAB were significant predictors of hospital LOS (R=0.60; p < 0.001); TBSA and PAB were significant predicters of ICU LOS (R=0.67; p< 0.000), days to wound healing (R= 0.37; p < 0.000) and days on nutrition support (R=0.60; p< 0.000). Albumin was not a significant predictor for any of the clinical outcome measures.

Conclusions

Our findings indicate that monitoring PAB and CRP is useful for identifying risk of poor outcome. Mean PAB was inversely associated with LOS, ICU LOS, days to wound healing, and days on nutritional support even when controlling for CRP and burn size.
534 Allogeneic Cellularized Living Tissue in Pediatric Deep Partial Thickness Burns Reduces Need for Donor Sites
Authors: Gibson Angela , Short Tracee , Joe Victor C
Published: March 2022

Introduction

Healing potential of deep partial thickness burns is not easily determined early after injury. Prolonged and continued inflammation can contribute to burn wound conversion. Early excision compared to a wait and see approach to wound healing decreases inflammation, shortens length of stay, and decreases painful wound procedures. However, early excision is at the expense of removing tissue that may otherwise heal without autografting. Use of a cryopreserved, allogeneic cellularized scaffold living tissue product (CTP) in pediatric deep partial thickness wounds with dermal elements remaining after excision is an alternative approach to wound closure. CTP may allow early excision without compromising healing potential, thereby minimize donor site morbidity, infectious complications and decrease length of stay. This case series describes the expanded access experience of a CTP on pediatric patients with thermal injury.

Methods

Expanded use approval of a CTP was obtained through the FDA for pediatric patients with burns at three burn centers. Patients were taken to the operating room for excision and grafting of burns at the discretion of the attending surgeon. In wounds with dermal elements present after excision, CTP was grafted to the wound bed (Table 1). Postoperative wound care and follow up was per institutional standards of care.

Results

Six pediatric patients (9 weeks – 13 years old) with mixed depth burns having dermal elements remaining after excision were treated successfully with a CTP. Donor site surface area was reduced in all patients. No serious adverse events related to the CTP were noted in any of the cases. Average time to heal wounds treated with the CTP was approximately 2-3 weeks. In wounds ultimately deemed to be full thickness, CTP was not detrimental to subsequent autograft take. See Table 1.

Conclusions

This case series demonstrates that use of a CTP in pediatric patients is donor site sparing without any serious adverse events. Furthermore, use in full thickness burns is not detrimental to subsequent autograft take. The degree of dermal elements necessary to support wound healing is unknown and requires further study. This case series supports the application for a clinical trial investigating the safety and efficacy of CTP as an adjunct to wound healing in pediatric deep partial thickness burns.
548 Toward a Burn Risk Calculator
Authors: Bessey Palmer Q , Phillips Bart D , Phillips Matthew H , Mandell Samuel P , Thompson Callie M
Published: March 2022

Introduction

Risk adjusted statistical modeling of deaths in burns has two major purposes. One is to enable comparison of outcomes between centers (Benchmarking). That requires as precise a model as possible and is applied retrospectively. The other objective is to inform patient and family discussions about prognosis and plans of care. These models are applied prospectively based on limited clinical data. The purpose of this study was to derive a model that could be the basis for such a risk calculator.

Methods

We identified 128,252 records in a national burn registry for initial patient admissions to 103 burn centers between July 2015 through June 2020. Cases from centers with < 100 admissions annually were omitted. We compared a logistic regression model based on the revised Baux score (RBS) (age, burn size, inhalation injury) with a logistic regression model involving age, age2, burn size, presence of 3rd degree burn, inhalation injury, respiratory failure, burn etiology, gender, and admission year. We compared the Adjusted R2, c statistic and average precision for each model. All calculations were done using CatBoostClassifier in Python.

Results

There were 127,018 patients that served as the basis for these analyses. The RBS model had an Adjusted R2 of 0.41 compared with 0.54 for the more detailed model, a c statistic of 0.95 vs 0.98, and an average precision of 0.69 vs 0.76.

Conclusions

Both statistical models of mortality following burn injury demonstrated good accuracy. The model with the most predictor variables had better precision. Both models could serve as useful risk calculators for patients following burn injury.
555 The Art of Caring
Authors: Quinn Kristen C , McCoy Nan , Strawn Mary A , Thompson Callie M , Lewis Giavonni M
Published: March 2022

Introduction

Providing Burn Care is a physically and emotionally demanding job. AND, it is a rewarding and inspiring profession. 2020 and 2021 saw unprecedented rates of burn out and turn over in staff. Our concern for the well being of staff as well as our need to increase retention motivated our desire to provide staff with tools to build resiliency and coping strategies. Traditionally, this education comes in the form of teaching mindfulness, breathing exercises or self care outside of the burn center. We recognized that while these approaches are important and effective, they are not the right fit for everyone. The current times require us to use a multipronged approach to the tools we offer our burn teams.

Our regional burn center partnered with a community based arts education nonprofit to re-think how we provide staff with tools for adaptability. A curriculum was formulated that provided therapeutic art to nursing staff via four weekly zoom meetings. This resulted in a novel approach to resiliency building and self care.

Methods

The program was opened to all burn center staff members. Staff registered in advance for the four week program; the arts organization mailed each participant a box containing all the supplies they would for need. Each week, a different art modality/artist was paired with therapeutic discussions grounded in a trauma informed approach. Discussions focused on emotional and physical safety, building a community of support, finding balance between work and home and identifying coping skills to use to help ground ourselves during times of stress.

Results

Seven burn center staff members signed up for this program. Weekly attendance averaged 6-7. A program evaluation was completed by participants at the end of the final session. Questions were divided into three sections: program logistics, community building and the artistic process. Results indicated that this was an extremely valuable experience for participants. In addition, staff made comments such as "allowing myself to be vulnerable in the process has built trust and connection between myself and the other participants", "I don't remember the last time I did something like this just for myself", "I feel like I can add art to my list of coping strategies, despite never thinking of myself as an artist".

Conclusions

Offering burn center staff with an alternative program to help build resiliency resulted in an increased sense of trust between staff members, provided one more outlet for self care and allowed participants to build resiliency in a new way.
573 Interfacility Transfers for Burn Patients with Concomitant Traumatic Injuries
Authors: Kirkland Kevin D , Gratton Austin , Mentzer Caleb , Kubasiak John , Yon James R
Published: March 2022

Introduction

Burn patients with concomitant traumatic injuries suffer increased morbidity and mortality. Complex care coordination for these patients often requires interfacility transfers. We sought to examine the outcomes for traumatically injured burn patients to identify the occurrence and associated reasons for trauma system transfers in this group.

Methods

The National Trauma Data Bank was examined from years 2007 to 2016 for 6,565,577 patients with traumatic, burn, and concomitant burn & traumatic injuries to evaluate demographic data, ED and hospital dispositions, length of ICU stay, ventilator days, mortality, and interfacility transfers. There were 5,068 patients with both traumatic and burn injuries, 145,890 patients with burn injuries, and 6,414,619 patients with traumatic injuries. Non-parametric Kruskal Wallis, analysis of variance, chi-square, Mann Whitney, and T-tests were utilized for comparisons.

Results

Patients were 69.1% male in the trauma/burn, 67.1% male in the burn, and 62.2% male in the trauma groups (P< 0.001). Trauma/burn patients were more often admitted to the ICU from the ED at 35.5% compared to 27.1% for burn and 19.4% for trauma (P< 0.001). ICU stay was longer for trauma/burn patients at 5.00 median days (IQR 2.00, 15.00) versus 3.00 (IQR 1.00, 10.00) for burn and 3.00 (IQR 1.00, 5.00) for trauma (P< 0.001). Trauma/burn patients had more ventilator days at 3.00 median days (IQR 1.00, 11.75) compared to 2.00 (IQR 1.00, 9.00) for burn and 2.00 (IQR 1.00, 7.00) for trauma (P< 0.001). Trauma/burn patients had increased mortality at 4.9% versus 2.5% for burn and 3.2% for trauma (P< 0.001). For hospital disposition, trauma/burn patients required more interfacility transfers 2.5% compared to 1.7% for burn and 1.3% for trauma (P< 0.001). For level 1 trauma centers, 5.5% of trauma/burn, 7.1% of burn, and 0.5% of trauma patients required interfacility transfers. For level 2 trauma centers, 29.1% of trauma/burn, 47.0% of burn, and 2.8% of trauma patients required interfacility transfers.

Conclusions

Among level 1 and level 2 trauma centers, patients with only burns and burn patients with concomitant traumatic injuries required more interfacility transfers, and level 2 trauma centers required more interfacility transfers for all patients.
587 Ambient temperatures in the burn operating room: A QI initiative
Authors: Rogers Alan D , Cartotto Robert , Wallace David L , Moltaji Syena
Published: March 2022

Introduction

Patients with burn injuries are particularly susceptible to perioperative hypothermia, which is associated with a range of complications, including infection, bleeding and delayed wound healing. Raising the operating room (OR) ambient temperature is an important strategy to prevent hypothermia, but we were uncertain about how strictly we do this. The purpose of this study was to determine the ambient OR temperatures during acute burn surgery as the first step of a quality improvement initiative to ensure we are maintaining a warm OR environment.

Methods

Between 1/3/2020 and 28/2/2021, ambient temperatures during surgery in the burn OR of an ABA-verified burn center were recorded every 15 minutes. Temperatures were measured using a wall-mounted smart sensor, transmitted to a mobile smartphone application via Bluetooth. All patients undergoing acute burn excision and closure procedures lasting > 2 hours were included in the study. Hypothermia was defined as a core temperature < 36°C.

Results

Of the 119 patients, the majority were male (n=86; 72.3%), the mean age was 49.8 years (range 18-89) and the mean total body surface area (TBSA) was 15.8% (range 1-62%). They underwent 261 operations (mean 2.2 cases per patient; range 1-15) with a mean duration of 211.1 minutes (range 120-468 minutes). Sixty-two patients underwent 1 surgery, and 31 had 2 surgeries. Eight patients (6.7%) died. Thirty-three patients (27.7%) were hypothermic at the end of 43 cases (16.5%).

The mean ambient temperature was 24.8oC (range 18.7oC to 29.6oC). Hypothermic patients (n= 33 patients, 43 cases), did not differ significantly in age or operative duration from non- hypothermic patients (n= 86 patients, 218 cases) but did have significantly larger %TBSA burns [32.3 vs 24.8 (p= 0.02)]. Hypothermic cases experienced significantly lower ambient temperatures at the start of surgery (p=0.007), and mean temperature during surgery (p=0.009), and tended to experience a lower ambient temperature at the end of surgery (24.5 C vs 25.1 °C , p= 0.06). [Table]

Conclusions

We have identified that the ambient temperature in our burn OR is lower than desirable and that this is directly related to development of hypothermia. These results now indicate that a QI intervention (stricter attention and manoeuvers to ensuring a warm operating room at the start and during surgery) is required.
591 Transition to an Advanced Practice Provider led burn service: process and lessons learned
Authors: Bard Maryke , Lewis Lauren , Ward Christopher , Frabotta Anna , Lou Richard B , Crow John , Khandelwal Anjay
Published: March 2022

Introduction

Burn is not a required rotation for general surgery residency training. Additionally, mandates on resident work hours have created a deficiency in resident support for many burn programs across the country. Subsequently, the need to transition to an Advanced Practice Provider (APP) service was identified. At our institution, a medium volume (~250 admissions/year) burn center, we created an APP service and evaluated the evolution and lessons learned during the transition.

Methods

Timeline of recruitment of APPs was reviewed along with the recruitment process, onboarding process and orientation process. Exit interviews were conducted with all APPs who resigned to delineate strengths and weakness of the APP program. Functionality of the institution’s APP recruiter, manager and Lead Burn APP (LAPP) were reviewed as well.

Results

Between 2014 and 2021 the daytime burn APP service expanded from two to six APPs and the Night House Officer (NHO) APP service was created and expanded to four APPs. Based on thorough review of the APP program, key changes were made including improvements in team communication, daily nurse-driven rounds, the 90-day focused professional performance evaluation (FPPE), enhanced and structured education, and critical care exposure.

The need for a LAPP was identified and designated in 2019. The LAPP is responsible for making an equitable schedule, execution of new APP orientation, organizing the 90 day FPPE and ongoing professional performance evaluation (OPPE), monthly APP peer review and APP meetings, coordinating OR coverage, and functioning as an APP advocate at division leadership. The LAPP enacted changes to the existing hiring/onboarding process as described below.

All APPs are now recruited through an APP recruiter who discusses the hospital contract and salary as well as organizes the logistics of the interview, formalizes the offer, and aids with the transition to credentialing. All new APPs are given a hospital onboarding checklist, that includes hospital orientation, APP boot camp, simulation and electronic health record training classes. In addition they are given a clinical orientation checklist, which includes BLS/ABLS/ACLS/ATLS certification, exposure to various phases of patient care, tracking of quantitative patient care metrics, participation in monthly burn APP peer review and burn triage simulation. There are subtle differences with the NHO APP clinical checklist. After 90 days of employment a new employee FPPE is held with the LAPP and burn director. This allows for direction of areas to focus on, comprehensive feedback, and discussion about increasing autonomy.

Conclusions

Through a focused process, APPs can play an integral role in the daily functioning of a burn center. We believe that a similar effective and financially sound model can be created for similar sized units.