bluuebunny/crossref_metadata_2025 huggingface dataset:
89 Antimicrobial Resistance Pattern and Prevalence of Extended Spectrum Beta-lactamase in Non-fermenting Gram Negative Bacteria, Isolated from Burn Wounds: A Prospective Study from a Tertiary Burn Center
Authors: Naderi Niyousha , Safdarpour Armin , Hakemi-Vala Mojdeh , Masoomi Hossein
Published: March 2020

Introduction

Burn wound infections are one of the major causes for long-term hospitalization and mortality among patients with thermal injuries. Identifying the bacterial cause of infection and determining the appropriate antibiotic to treat these infections is an important stage in treatment. The aim of this study was to investigate antimicrobial drug resistance in non-fermenting gram-negative bacteria isolated from burn wounds in patients who were admitted to a tertiary burn center.

Methods

In this prospective study during a six-month period in 2018,100 isolates of non-fermenting gram-negative bacteria were collected from 100 patients with thermal injuries. Antibiotic susceptibility test was performed using the Kirby-Bauer method based on the clinical and laboratory standards institute guidelines. Double-disc synergy test, a phenotypic method, was used to identify strains producing extended-spectrum beta-lactamase (ESBL). Data analyses were performed using SPSS.

Results

A total of 100 wound samples were examined from 100 patients, 76% were male and 24% were female with a mean age of 33 years (range 1–89 years old). Mean total body surface area burned was 35% (range 1–95%) and mean length of hospital stay was 24 days (range 3–69 days). Eighty five percent of cases were under 50 years old. Overall mortality rate in this study was 17%. The major causes of burn were liquefied natural gas tank explosion (35%) and scalds (19%). Acinetobacter baumannii (A.baumannii) was the most common pathogen followed by Pseudomonas aeruginosa (P.aeruginosa) (60% and 40%, respectively). ESBL producing rate was significantly higher in P.aeruginosa isolates (27.5%) than A.baumannii isolates (3.3%) (P-value < 0.001). Antibiotic resistance pattern of P.aeruginosa showed the highest resistance to ciprofloxacin, amikacin and imipenem (95%), followed by gentamicin (92.9%),ceftazidime(87.50) and piperacillin-tazobactam(85%). Antibiotic resistance pattern of A.baumannii showed the highest resistance to ceftazidime(100%) followed by ciprofloxacin, amikacin, imipenem(98.3%), gentamicin and piperacillin-tazobactam (93.3%). Multiple drug resistance (MDR) rate among A.baumannii and P.aeruginosa was 98.3% and 92.5% respectively, which is higher than previous reports.

Conclusions

A.baumannii and P.aeruginosa were the most common pathogens identified in this cohort with a significant MDR rate (over 95%). New strategies to control expansion of antimicrobial resistance in burn centers are necessary.

Applicability of Research to Practice

This study shows the antimicrobial resistance pattern and prevalence of ESBL in burn wounds indicating that further studies requires to identify new strategies to control emerging antimicrobial resistance in burn centers.
97 Burns in the Military Setting- analyzing 12,799 Routine & Combat Cases
Authors: Yaacobi Dafna (Shilo) , Lvovsky Alex , Ad-El Nitay , Levi Diana , Glick Yuval , Furer Ariel , Ad-El Dean D
Published: March 2020

Introduction

Burns are an important part of military trauma injuries. Studying the epidemiology, due to large morbidity related issues, is important for decision makers.

The aim of the study is to review and characterize the burn injuries that occurred in the Israel Defense Forces (IDF) during the years 2008–2016 in training, routine and war. The burn area, degree, setting, unit, etc. will help us characterize the etiology, severity and consequences which is crucial in developing and directing resources to prevention and treatment programs.

Methods

All burn injuries in 2008–2016 were retrieved (ICD-Z 940–949). Data was collected from the IDF military medical records and included 3 months of follow-up. We retrieved 65,536 medical records, which included follow up of 12,799 soldiers. Special algorithms were specifically designed to retrieve and analyze variables included.

Distribution analysis was performed, Parametric Kruskal–Wallis test was used and Chi Square test was used for comparing categorical variables.

Results

During the years 2008–2016, 65,536 burn related visits were retrieved and 12,799 burn injuries were identified. Gender distribution in figure 1.

Gradual decrease in burn injuries was identified (figure 2). Distribution by Setting (figure 3), Commands (figure 4), Etiologies (figure 5), and etiologies within commands (figure 6).

Average Total Body Surface Area (TBSA) was 7.524% (figure 7) and also declined over the years (7.7% in 2008 to 7.1% in 2016).

Conclusions

The decrease in burn rate could be attributed to the increased awareness of soldiers due to the emphasis given to health education and preventive medicine, as well as to improved protection.

Scald and flame replaced by chemicals as the leading etiology, It is hypothesized that a small part of chemical burns is a result of self-infliction, which is more prevalent at non-combat units.

Average Total Body Surface Area (TBSA) was similar but lower than other studies.

The nature and operation mode of the IDF must be kept in mind- a relatively small army composed mainly with obligatory servicemen, there are no dedicated military hospitals, major trauma can be transported directly to the civilian medical system and not appear in the military medical charts.

Applicability of Research to Practice

This extensive report shows the trends and characteristics of burn injuries in the IDF, allowing for better understanding of these important injuries, and concluding for target health education based on common etiologies and at-risk populations and commands.

IDF Commanders should preserve the current burn prevention educational programs, and protection instruments such as uniforms, special gloves and eye protection appliances, since they seem to work, and improvement was observed.

Education should also focus on proper handling of various chemicals, and if self-inflicted suspected- psychological intervention should be considered.
99 Hand Burns: An Independent Risk Factor for Worse Hospital Outcomes
Authors: Pham Christopher H , Collier Zachary J , Sheckter Clifford C , Yenikomshian Haig A , Gillenwater Justin
Published: March 2020

Introduction

Hand burns cause disability, loss of productivity, and psychological distress. While rarely life-threatening, hand burns are life-altering. There are limited large-scale investigations on the prevalence of hand burns and the impact on hospital outcomes. We present the first National Burn Repository (NBR) study on the prevalence of hand burns and associated outcomes.

Methods

We used NBR Version 8.0 to identify patients who sustained isolated and non-isolated hand burns. These patients were then sub-stratified into operative vs. non-operative hand burns and compared with non-hand burns as controls. Patient demographics and hospital outcomes (mortality, length of stay [LOS], intensive care unit LOS [ICU LOS], hospital charges) were collected. Multivariable logistic and multiple linear regressions determined the effect of hand burns on outcomes adjusting for age, %TBSA, full-thickness involvement, and inhalation injury.

Results

Of 172,640 NBR patients, 47,424 patients had hand burns and 5,870 (12%) were operative. Patients with hand burns had significantly larger %TBSA burns (12±18% vs. 7±8%, P< 10–4), more full-thickness involvement (6±16% vs. 2±6%, p< 10–4), a higher prevalence of inhalation injury (7% vs. 5%, p< 10–4), were more often male (73% vs. 66%, p< 10–4), higher mortality (5% vs. 2%, p< 10–4), longer LOS (12±22 vs. 8±21 days, p< 10–4) and ICU LOS (7±18 vs. 3±10 days, p< 10–4). Similarly, operative hand burns had longer LOS (25±30 vs. 10±20, p< 10–4) and ICU LOS (25±29 vs. 12±22, p< 10–4) but lower mortality (3% vs. 6%, p< 10–4) than non-operative hands. When controlling for age, sex, TBSA, full-thickness involvement, and inhalation injury, the presence of hand burns significantly predicted higher mortality (OR=1.6, 95% CI 1.5–1.8, p< 10–4) and prolonged ICU stays by 0.79 days (p=0.003), but was not associated with prolonged LOS (p >0.05). Billing data revealed significantly higher hospital charges ($114,608±294,289 vs. $58,314±158,758, p< 10–4) in patients with hand burns (N=17,140) compared to those without (N=12,530).

Conclusions

Patients with hand burns had worse inpatient outcomes and were also more costly to the healthcare system. Practitioners must pay close attention to hand burns as the cost to the system and society warrants improved management. In a society increasingly focused on value and quality, additional investigations are needed to understand how we can better treat hand burns to decrease inpatient morbidity.

Applicability of Research to Practice

Granular data for the hospital course of patients with hand burns may better elucidate why they require more healthcare resources than others.
112 Improvements in Burn Hypertrophic Scar After Fractional Ablative Laser Scar Revision
Authors: Travis Taryn E , Allely Rebekah R , Johnson Laura S , Shupp Jeffrey W
Published: March 2020

Introduction

Fractional ablative laser therapy use is increasing for treating burn hypertrophic scar (HTS). However, standard components of a routine HTS evaluation prior to starting laser scar revision (LSR) and after each intervention have yet to be determined, and metrics for effective treatment have not been established.

Methods

Patients who entered a LSR program between September 2018 and September 2019, underwent at least two LSR treatments, and completed post-LSR scar evaluations for each of these treatments were included in the studied sample. Patients were treated with a fractional ablative CO2 laser. A single burn rehabilitation therapist conducted all pre- and post-procedure scar evaluations, which included the Patient and Observer Scar Assessment Scale (POSAS), Vancouver Scar Scale (VSS), Institutional Scar Comparison Scale (SCS), durometry, and active range of motion (AROM) measurements.

Results

From 9/2018 to 9/2019, 25 patients began the LSR program and underwent at least two treatments with post-laser scar assessments for each intervention. Patients underwent an average of 3±1 LSR sessions during the time period for a total of 84 sessions amongst the group. Patients averaged 51±14 years old (range 26–80), with all Fitzpatrick skin types represented (mode type 5). Average HTS age was 14±19 months post-injury (range 3–98 months post injury).

After one session of LSR, 91% of patients improved in at least one scar assessment metric (average 3±1.4 areas). After two sessions, all patients showed improvement in at least one metric (average 3.6±1.2 areas). One LSR session was associated with a 10.8±31.9% improvement in AROM of a HTS-affected joint, and this increased to 38.1±41.4% after five LSR treatments (p=0.0002). Durometry readings demonstrated decreasing scar hardness compared to adjacent uninjured skin in 90% of patients, and 96% of patients experienced improvements in POSAS, VSS, and SCS scores during a treatment course.

Conclusions

Improvements in burn HTS can be achieved with fractional ablative laser therapy in a wide range of scar ages and skin types, as early as the first LSR session. These continue to increase as additional sessions are performed.

Applicability of Research to Practice

This work suggests necessary baseline evaluation components for patients undergoing LSR, as well as a timeline for expected clinical improvements. This data may inform conversations with burn survivors and providers when considering laser therapy for symptomatic HTS.
115 Predicting Graft Failure in a Porcine Burn Model of Various Debridement Depths via Laser Speckle Imaging and Deep Learning
Authors: Liu Nehemiah T , Stone Randolph , Salinas José , Christy Robert J
Published: March 2020

Introduction

Early excision and grafting (E&G) remains a mainstay in the treatment of burns. Procedures to remove necrotic tissue from severe burn wounds continue to be challenging and may affect rates of successful grafting. The use of laser speckle imaging (LSI) may help detect necrotic tissue remaining but requires human interpretation. Additional decision-making support is needed, especially in prolonged field care settings. The purpose of this study was to evaluate whether graft success or failure can be predicted from LSI using machine learning (ML) and deep learning (DL) techniques in a porcine burn model of various burn depths.

Methods

Anesthetized Yorkshire pigs (n=12) were burned with a 5x5 cm square brass block (0.4 kg/cm2) @ 100°C to produce partial, deep partial, or full thickness burns (PT, DPT, FT) at 10 square sections on the back of each pig. Debridement was randomized from 1 (0.030”) to 4 (0.120”) passes performed using a dermatome, and then meshed split thickness skin grafts taken from 4 caudal donor sites were applied to wounds. Post-debridement was denoted as Day 0. Graft success/failure (>70% graft take) was determined at Day 7. Laser speckle images were captured at Days 0, 3, 7, 10, and 14. ML and DL were used to develop models in order to predict graft failure and burn/debridement depth. Model performance was measured using loss, accuracy, and confusion matrices.

Results

Of 120 sections corresponding to 12 pigs, 7.5% (9/120) were not burned, 41.7% (50/120) were PT, 25.8% (31/120) were DPT, and 25.0% (30/120) were FT burns. Graft failure was 19.2% (23/120), with a 50.0% (10/20) rate for DPT burns involving 1- or 2-pass debridement. Both ML and DL used 600 images for algorithm development; 540 images, for training; and 60 images, for testing. DL was superior over ML in test accuracy (93.3% vs 75.0%, p< 0.05). A three-stage architecture plus image resizing was employed in DL to predict graft failure and burn/debridement depth. A best convolutional neural network for graft failure prediction was obtained, yielding a minimum cross entropy loss of 11.7% and accuracies of 96.5% (training), 93.3% (testing 1), 100.0% (testing 2), and 96.2% (overall). Promising results were also obtained for predicting burn/debridement depth: 97.6% (training), 93.3% (testing).

Conclusions

This study showed that graft success or failure can be predicted from LSI and DL in a porcine burn model of various debridement depths. Use of this technology may provide a potential approach for accurately assessing early E&G in severely burned patients and may aid providers during prolonged field care scenarios.

Applicability of Research to Practice

Use of LSI in conjunction with DL may provide a potential approach for accurately assessing early E&G in severely burned patients and may aid providers during prolonged field care scenarios.
500 Intracranial Injuries and the Effect of Fluid Resuscitation in Burn Patients
Authors: Williams Alicia M , Stephens Brian , Rizzo Julie A , Frattalone Anthony R , Chung Kevin K , Ainsworth Craig , Cancio Leopoldo C
Published: March 2020

Introduction

Few studies exist that describe the neurologic injuries seen in patients admitted to the burn ICU. Patients who have sustained a severe thermal injury undergo complex metabolic, hemodynamic, and inflammatory changes and require aggressive fluid resuscitation. The neurologic consequences of burn-associated resuscitation may have clinical implications. The purpose of this study was to evaluate the intracranial neurologic injuries and how they relate to volume of burn-related resuscitation fluids administered.

Methods

We performed a retrospective analysis of all patients admitted to the Burn ICU at a single facility between January 2003 and June 2017. Patients were included if they were admitted within 24 hours of their burn injury and obtained head computed tomography (CT) for any indication in the first 96 hours of hospitalization.

Results

Of a total 5176 patients admitted, 439 met the inclusion criteria. An acute intracranial process was identified in 41 cases. 27 patients received 0–150 cc/kg of IV fluids, while 11 received >200 cc/kg during the first 24 hours. The most common injuries in the former were hemorrhage (subarachnoid, intraparenchymal) and edema (7/27 for each), while ischemia/infarction (4/11) was the most frequent in those receiving >200 cc/kg. Follow up imaging was more likely to be worse in the >200 cc/kg group (5/11) than in the < 150 cc/kg group (2/27).

Conclusions

Of patients admitted to the Burn ICU within 24 hours of injury and who received a head CT within the first 96 hours, an acute intracranial abnormality was found in 8% of patients. The most common diagnosis was hemorrhage in those receiving < 150 cc/kg of IV resuscitation, while ischemic/infarction was more common in those receiving >200 cc/kg. Follow up imaging in those receiving more IV fluids was more likely to demonstrate worsening, which could suggest that increased resuscitation leads to worsening intracerebral outcomes.

Applicability of Research to Practice

Having a high index of suspicion for intracranial complications related to resuscitation improves the multi-disciplinary team’s ability to prevent, identify early and treat appropriately in order to improve patient outcomes.
506 Anticoagulation After Thrombolytic Treatment for Frostbite: A Case Series
Authors: Garza Amanda M , Zavala Sarah , Sanford Arthur , Baldea Anthony J , Liu Yuk Ming
Published: March 2020

Introduction

Historically, management of frostbite followed the adage “freeze in January and amputate in July.” While rapid rewarming primarily addresses the ice crystal formation phase of damage, vascular injury and resulting thrombosis result in the overall tissue damage. Over the last two decades, limb salvage for frostbite has been widely employed. The use of tissue plasminogen activator (tPA) to prevent vascular thrombosis has been found to reduce the number of digit amputations and benefit of systemic thrombolytic therapy has been demonstrated. Post-thrombolysis anticoagulation has changed as well. Our institution has changed its protocol from using warfarin after tPA therapy to aspirin (ASA) for ease of adherence. This study evaluates the use of warfarin or aspirin for management after tPA therapy.

Methods

This was a retrospective review of patients who received tPA for frostbite between January 2008 and April 2019. Data collected included age, height, weight, sex, past medical history, contributing factors to development of frostbite, toxicology screen on admission, cold exposure time, rewarming time, number of digits/limbs affected, and highest grade of injury. Outcomes data included medications received, number of digits/limbs amputated, length of stay, and number of follow up visits.

Results

Ten patients were included in the statistical analysis, 7 patients in the ASA group and 3 patients in the warfarin group. Baseline demographics were similar between groups, except the ASA group was significantly younger (31.9 vs 64.7 years, p < 0.001) and weighed less (70.3 vs 86.8 kg, p = 0.02) than the warfarin group. Statistical analysis demonstrated no significant difference in outcomes when comparing patients managed with ASA 325 milligrams (mg) versus warfarin after tPA therapy. The average number of limbs amputated for patients taking ASA was 0 + 0.0 and was 0.7 + 1.2 for those taking warfarin (p=0.42). Average number of digits amputated for patients taking ASA and warfarin was 0.1 + 0.4 and 3.7 + 5.5, respectively (p=0.38). For patients who took ASA, length of hospital stay averaged at 8.0 + 4 days, while those who took warfarin stayed for 9.4 + 7.2 days (p= 0.64). Finally, the average number of follow up visits for patients who took ASA and warfarin was 3.9 + 4.7 and 8.0 + 9.6, respectively (p=0.37).

Conclusions

These findings indicate that there may not be a significant difference in clinical outcomes when comparing patients who took ASA to warfarin after tPA therapy. It is common for patients to have a delayed presentation and prolonged rewarming time, resulting in ineligibility to receive tPA. Single center frostbite studies are limited due to sample size and multi-centered studies are necessary for future studies.

Applicability of Research to Practice

ASA 325 mg daily may be a suitable alternative to warfarin therapy after tPA administration following a frostbite injury.
508 Fungal Infections in Burn Patients from 2014–2019: A 5-year Retrospective Review
Authors: Pruskowski Kaitlin A , Rizzo Julie A , Cancio Leopoldo C
Published: March 2020

Introduction

Topical and systemic antibiotic agents used to treat burn wounds allow for fungal growth. Fungal infections often occur later in the hospital course and carry a higher mortality rate than bacterial infections in critically ill burn patients. The primary objective of this study was to describe the incidence and characteristics of fungal infections in our burn center.

Methods

This was a retrospective chart review. Subjects who were admitted between January 2014 and February 2019 after sustaining a burn injury and received a systemic antifungal agent were included. All cultures and histopathology results that were positive for fungus were recorded.

Results

Ninety one subjects were included in this analysis. The average age was 42.3±16.9 years and 74 (81.3%) subjects were male. Seventy four (81.3%) subjects were admitted after flame burn. The average burn size was 40.1±24.2% TBSA. The average hospital length of stay was 57.2±44.8 days. Thirty eight (41.7%) subjects died during their hospital stay.

The 91 subjects had 220 cultures positive for fungi: 29 blood cultures, 19 BAL cultures, 23 sputum cultures, 118 tissue cultures, and 31 urine cultures. The most common fungal genera isolated were: Candida (n=146), Aspergillus (n=55), and Fusarium (n=44).

Twenty six (28.6%) subjects had histopathology results that showed fungus in non-viable tissue, with an average time from injury to fungus of 20.4±11.8 days. Twenty six (28.6%) subjects had histopathology results that showed fungus in viable tissue, with an average time from injury to fungus of 22.7±16.7 days. Of note, these were not the group that had fungus in non-viable tissue. Twelve (13.2%) subjects had angioinvasion, with an average time to angioinvasion of 26.6±22 days.

The 91 subjects received 133 courses of antifungals. The average course of antifungal therapy was 7.8±8.9 days. The most common antifungals used were: micafungin (n=54), fluconazole (n=53), and liposomal amphotericin B (n=44).

Conclusions

Patients who were started on a systemic antifungal had a high mortality rate. Common fungi isolated included Candida and Aspergillus, which is consistent with previous literature. Further research is needed on the early recognition, accurate diagnosis, and timely management of fungal infections in this patient population.

Applicability of Research to Practice

Fungal infections after burn injury carry a high mortality rate. Early recognition and timely management of these infections is paramount.
511 Point-of-care 3-dimensional Body Mapping for Determining Total Body Surface Area in Severely Burned Patients
Authors: Loegering Julia , Webb Kevin , Ahlquist Jesse , Krause Kevin , Xu Karen , Greenhalgh David G , Palmieri Tina L , Tran Nam K
Published: March 2020

Introduction

With severe burn injury, there is systemic fluid loss due to inflammatory responses in damaged tissue, leading to disruption of cellular processes. Patient fluid levels are restored with the calculation of total body surface area (TBSA). Clinically used TBSA equations are often outdated and inaccurate with error up to 20%, resulting in misinformed treatment and subsequent sequelae including prolonged hospital length of stay and increased mortality. Our objective, therefore, was to create a point-of-care (POC) system employing 3D imaging technology to accurately calculate TBSA for all patient population varieties.

Methods

Our team employed an iPad attachable, infrared scanner to create 3D models of the human body. From these models, TBSA can be extrapolated using scan processing software. Subject scans were collected on our device and on a gold standard scanner for comparison of TBSA output. Clinical testing on burn patients is occurring at present to establish scanning precision of TBSA in the burn care environment.

Results

Non-clinical verification tests of the 3D scanned TBSA revealed a 4.05% error when compared to the gold standard, and precision error of 3.8%. Additionally, we introduced the device into the burn unit for preliminary testing with a physician user and non-patient subjects. The subjects were scanned in a prone position to mimic burn care workflow. Clinician scanning error was 1.41% when compared to the gold standard scan of the same subject. Clinical precision study results are on-going in collection.

Conclusions

Our device introduces an improved method of TBSA estimation to assist clinicians in making accurate burn care decisions and further precision medicine with greater anthropomteric data, notably for children. This device is one of the first POC-3D scanning technologies to be used in a burn setting and may also be employed at outlying medical facilities. Destructive wildfires and combat burn injuries highlight the need for such a device to standardize the triage of burn victims with and away from experienced medical staff.

Applicability of Research to Practice

3D body mapping points to an enhanced method of TBSA calculation and minimally disruptive to the burn workflow. Future developments of 3D scanning include deep learning algorithms to identify and better assess burned surface area. Additionally, further automation of TBSA scan processing to reduce user error in calculation and improve burn injury outcomes.
512 Single Center Experience with Venous Thromboembolism Prophylaxis for Obese Burn Patients
Authors: McKinzie Brian , Nizamani Rabia , Jones Samuel W , Williams Felicia N
Published: March 2020

Introduction

Burn injured patients are at high risk of thromboembolic complications. Morbid obesity further increases risk for thromboembolic complications. Recent evidence supports the use of anti-Xa guided enoxaparin dosing for the prevention of venous thromboembolism (VTE) in high risk populations. Our objective was to evaluate the efficacy of enoxaparin 40mg twice daily in achieving prophylactic plasma anti-Xa levels in obese burn patients.

Methods

A retrospective chart review of an ABA-verified burn center from November 2018 until September 2019 identified patients who were either ≥100 kilograms (kg) or had a body mass index (BMI) ≥ 30 kg/m2 and were initiated on enoxaparin 40 mg twice daily for VTE prophylaxis. Patients were included if they were at least 18 years of age and received at least three sequential doses of enoxaparin with appropriately timed peak plasma anti-Xa levels to monitor efficacy. Patient demographics were analyzed, as well as body weight, BMI, and total body surface area (TBSA) burn. Statistical analysis was performed with student’s t-test for continuous data and Fischer’s exact test for categorical data.

Results

During the study period, 148 patients were screened with 44 patients included for analysis. Forty-one percent of the patients evaluated did not reach target peak plasma anti-Xa levels (0.2–0.5 IU/mL) on enoxaparin 40 mg twice daily. Patients who did not meet prophylactic target levels were more likely to be male (p< 0.05) and have an increased body weight (129 +/- 24 kg versus 112 +/- 17 kg, p< 0.05). Eleven out of 18 patients received dosage adjustments with subsequent anti-Xa levels available for follow-up assessment, of which an additional four patients required further dosage adjustment to meet goal peak plasma levels.

Conclusions

Current utilization of a fixed 40 mg twice daily regimen of enoxaparin for VTE prophylaxis is inadequate to meet target prophylactic peak plasma anti-Xa levels in the obese burn patient population. Dose adjusting enoxaparin to target peak plasma anti-Xa levels to reduce VTE rates in obese burn patients should be further evaluated.

Applicability of Research to Practice

This study demonstrates the need for more accurate dosing and evaluation of our dosing practices for VTE prevention. It also demonstrates the importance of having a Burn dedicated pharmacist in facilitating appropriate care.
517 ALDEN Based Determination of Culprit Drugs in Stevens-Johnson Syndrome: A 15-year Single Center Review
Authors: de Bustros Paul M , Baldea Anthony J , Sanford Arthur , Bouchard Charles , Joyce Cara
Published: March 2020

Introduction

Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis Syndrome (TENS) are severe and potentially lethal adverse drug reactions characterized by acute inflammation and subsequent necrosis of the skin, mucous membranes, and ocular surface. SJS/TENS is defined on a spectrum based on the percent of total body surface area (%TBSA) with epidermal detachment: SJS (< 10% TBSA), Overlap Syndrome (10–30%), and TENS (>30%).

The purpose of our study was to perform a systemic retrospective trend analysis of SJS spectrum diagnoses and culprit drugs in 147 patients admitted to the burn center over the past 15 years with the final diagnosis of SJS/TENS. The burn center serves as a regional referral center for patients with suspected or confirmed SJS/TENS. These referrals came from the five other academic medical centers as well as private hospitals in the area.

Methods

The electronic medical records of patients with a confirmed diagnosis of SJS/TENS admitted to the burn center from 2002 to 2017 were reviewed. Clinical data and the algorithm of drug causality for epidermal necrolysis (ALDEN) were used to identify the single most probable culprit drug. The following data were reviewed: date of admission, %TBSA with detachment, biopsy confirmation, and possible inciting agents. Chi-square tests were used to assess statistical significance for group comparisons.

Results

Over 15 years, 147 patients had a biopsy-confirmed diagnosis of SJS/TENS, of which 67% (n =98) had a culprit drug identified. The most common spectrum classification was TENS (n=73), followed by SJS (n=46) and Overlap Syndrome (n=27). Anticonvulsants (n=24), fluoroquinolones (n=14), allopurinol (n=11), sulfa drugs (n=9), and NSAIDs (n=9) were the most common inciting agents. Between 2006–2017, the proportion of patients presenting with SJS increased as compared to TENS and Overlap syndrome (10% in 2002–2009 vs. 42% in 2010–2017, p< 0.01). Sulfa drug reactions were more prevalent in recent years (0% in 2002–2009 vs. 18% in 2010–2017, p=0.065) and fluoroquinolone-induced reactions in earlier years (21% in 2002–2009 vs. 6% in 2010–2017, p=0.068).

Conclusions

This is one of the largest single center series of SJS/TENS/Overlap cases in the US. Our data supports trends presented in the EuroSCAR (1997–2001) and RegiSCAR (2003–2012) studies.

Applicability of Research to Practice

The ALDEN algorithm provides an important and validated method for determining the probable culprit drug in SJS/TENS spectrum reactions. Trends in culprit drugs can shift over time based on changes in prescribing practices. Therefore, these trends need to be monitored in order to advise providers on which agents present the greatest risk to patients.
518 Relationship of Microbiome, Antimicrobial Resistance, and Wound Closure in >90% Burn Patients
Authors: Monahan Alison M , Dyamenahalli Kiran U , Barron Michelle , Duffy Patrick , Wagner Anne L Lambert , Wiktor Arek J
Published: March 2020

Introduction

Patients with 90% or greater total body surface area (TBSA) burns of face many unique challenges, including prolonged open wounds and antibiotic use. Furthermore, increased antibiotic use can be associated with increased antibiotic resistance. Despite the commonality, the relationship between prolonged wound closure (months) combined with prolonged duration of antibiotic use (months) has not been fully explored. The specific aim of this study was to examine the evolution of burned patients’ microbiome over time in association with wound healing and antibiotic use.

Methods

We conducted a retrospective review of all patients admitted to our ABA-verified burn center from 2010-present with 90% TBSA or greater burns who survived to discharge. Demographic data, length of stay, percentage monthly wound closure (including donor sites), microbial culture data of bacteria, yeast, fungus, and mold (YFM), antibiotic susceptibilities, and systemic antimicrobial agents administered were recorded. Statistical analysis was performed using Pearson correlation coefficient.

Results

Two patients met inclusion criteria. Patient A (PtA), a 36 year old (yo) female with 95% TBSA burns and Patient B (PtB), a 45 yo male with 90% TBSA burns. Patients spent a combined 766 days (PtA 425, PtB 341) as inpatients. 347 separate positive cultures were analyzed, 180 of which were bacterial. 15 distinct species of bacteria were cultured (8 PtA, 9 PtB), along with 4 subtypes of Pseudomonas aeruginosa, and 9 distinct YFM (6 PtA, 6 PtB). Increasing antibiotic resistance was found in 57% (PtA) and 71% (PtB) of bacterial species. Pseudomonas was the most commonly isolated organism in 65% (n=118) of cultures. The relationships between percent wound closure, daily antibiotic use, and Pseudomonas antibiotic resistance are shown in the Graph below. There was a strong correlation between wound closure of >50% with decreased amount of antibiotics used per day (PtA 0.83, PtB 0.86) and decreasing % of Pseudomonas antibiotic resistance (PtA 0.66, PtB 0.8).

Conclusions

Antibiotic resistance increases over time and efforts should be taken to decrease number of antibiotics administered. As wound closure passes a certain threshold, the number of antibiotics needed decreases, and Pseudomonas antibiotic resistance appears to decrease as well.

Applicability of Research to Practice

Recognition of different environmental pressures for bacteria may point to changes in microbial resistance patterns and thus clinical management.
529 Collagen Plus Alginate Wound Dressing for the Treatment of Split-thickness Skin Graft Donor Sites: A Cost-effectiveness Study
Authors: Sanches-Pinto Debora C , Mota Wellington M , Gomez David S , Gemperli Rolf
Published: March 2020

Introduction

The collagen plus alginate dressings for donor sites have been used in our country since 2003. Before that, the use of rayon was the main and only preference of use. We were looking for something new at that time that could be less painful and maybe presented a good relation cost-benefit. This alternative dressing seemed to offer collagen to the wound so that the imbalance of metalloproteases would be reduced. We started a study to evaluate the use of collagen calcium-alginate dressing for donor sites.

Methods

A prospective clinical study was conducted for 2010 to 2017, when this material was donated (high cost in our service). Patients were selected consecutively and randomly allocated into three groups according to the treatment used on the donor site: rayon soaked in 0.9% saline; rayon covered with sterile cotton gauze and bandage; 90% bovine collagen with 10% calcium-alginate dressing covered with transparent polyurethane film. Following parameters was comparatively analyzed: pain, time to epithelialization, length of stay and costs.

Results

We studied 30 patients, ranging from 12 to 60 years of age. Fifteen of these patients had their donor sites covered with collagen calcium-alginate dressing, which showed pain reduction of 79.5% (p< 0.01) shorter hospital stay and epithelialization, average of 5.8 days (p< 0.01) and reduction in hospital costs about 47% (p< 0.01) in comparison with rayon dressing. None presented infection in the donor site.

Conclusions

Collagen calcium-alginate dressing showed better cost-benefit than rayon to cover donor sites, with significant reduction of pain, epithelialization time, length of stay and costs.

Applicability of Research to Practice

cost-effective dressings and painless dressings, Burn care units, Ambulatory care.
545 The Association of Plastic Surgery Facility Volume with Inpatient Burn Outcomes
Authors: Sheckter Clifford C , Perrault David , Rochlin Danielle H , Chattopadhyay Arhana , Karanas Yvonne L
Published: March 2020

Introduction

Acute burn care involves a spectrum of physicians, nurses, and allied health professionals. Similarly, burn surgeons have variable training backgrounds that originate from different specialties. Plastic surgery was founded on the core principles of reconstruction and offers the full spectrum of acute burn care and reconstructive surgery. Previous work has shown that variations in practice within burn surgery are partially driven by training background. We hypothesize that plastic surgery involvement and access to the full reconstructive paradigm will improve inpatient outcomes in the treatment of burn injuries.

Methods

Acute burn patients with known percent total body surface area (%TBSA) were extracted from the National Inpatient Sample (NIS) from 2012–2014 based on International Classification of Disease 9th Edition codes. Plastic surgery volume per facility for the entire NIS was determined based on ICD-9 codes for flap procedures, breast reconstruction, and complex hand reconstruction. Outcomes included odds of receiving a flap, patient safety indicators (venous thromboembolic event, sepsis, surgical bleeding, pneumonia, wound complications) and mortality. Regression models included the following variables: age, %TBSA, gender, inhalation injury, comorbidities, hospital size, and urban/teaching status.

Results

The weighted sample included 99,510 burn admissions with a mean age of 37.2 years (standard deviation [SD] 24.3) and mean %TBSA of 12.4% (SD 12.4%). The weighted median plastic surgery volume by facility was 245 cases per year (Interquartile range 115, 495). Compared to the lowest quartile, the upper three quartiles of plastic surgery volume were associated with an increased likelihood of undergoing a flap procedure during admission (p< 0.05). Plastic surgery volume was also associated with decreased likelihood of patient safety indicator events, whereby the highest quartile showed an OR of 0.71 (95% confidence interval 0.59–0.85, p< 0.001). Plastic surgery facility volume was not significantly associated with a difference in the likelihood of inpatient death.

Conclusions

Burn patients treated at high volume plastic surgery facilities were more likely to undergo flap procedures during their admission compared to low volume centers. High volume plastic surgery facilities were associated with lower likelihood of inpatient complications, although there were no differences in mortality.

Applicability of Research to Practice

Inform health systems design in the delivery of burn care to provide the best outcomes for burn survivors.
559 Seasonal Variation in Hospitalizations for Burn Injuries
Authors: Shmelev Artem , Robinson Emmanuel , Quiroga Luis H , Hultman C Scott , Asif Mohammed
Published: March 2020

Introduction

Seasonal variation in traumatic injuries is a known phenomenon, but published data from large scale studies on burn hospitalization rates is sparse. We aimed to describe trends and seasonality in burns admissions using largest available administrative U.S. database with respect to percentage of total body surface area (TBSA) involved.

Methods

Study population was obtained from National Inpatient Sample 2000–2015 and included all primary admissions for burn injuries (n=490,247). Monthly hospitalization rates were calculated and seasonal trend decomposition was performed, including subgroup analysis by TBSA.

Results

The highest hospitalization rate was observed during summer months, with a peak in July. Seasonal differences were significant for burns with TBSA 10–39%. Seasonal amplitude accounts for 28% of total burns hospitalization rates. Increase of annual trends (2000–2015) reached significance for burns with TBSA < 10% and ≥40%, while admission rate for burns with TBSA 10–39% remained stable. Patients, admitted during summer months were more frequently younger males, had burns with TBSA >10%, shorter length of hospitalization and lower in-hospital mortality, compared to other seasons (all p< 0.001).

Conclusions

Observed seasonal variation in burns incidence could be related to summer peak in outdoors grilling and fire activities, although the mechanism of injury can not be captured by administrative databases.

Applicability of Research to Practice

Anticipation of summer peak can help burn units to allocate resources and bring attention of society to preventive measures while working with open fire.
560 So Much More Than Just a Good Time: A Qualitative Look at a Burn Camp Experience
Authors: Barr Michele , Marrale Kelley , Fields Anita , Chrisco Lori
Published: March 2020

Introduction

Parents do not send their children to burn camp only to have fun. Since inception over three decades ago, burn specific camps have reported many benefits. A qualitative review of a well-established camp confirms that parents primarily send their kids to camp for the peer related social benefits that extend beyond the recreational aspects of a camp experience.

Methods

A nine-question survey was sent electronically to households of 58 burn survivors between the ages of 7–15 during the week after their child’s burn camp experience. Open-ended questions allowed for unrestricted disclosure of thoughts, feelings, praise or criticism. Responses were evaluated for similarities or differences to determine frequency and relative importance. The data was coded and analyzed for correlations into emergent categories with agreement between reviewers.

Results

The overall survey response rate was 63%. Categorical analysis of parent responses indicated their primary motivation for having a child attend camp was for the “Shared Experiences” with other burn survivors. Results indicated the enjoyment or fun aspect of camp was the least important motivational factor behind a parent’s decision. Analysis of the perceived benefits were social in nature, with “Connection” listed as the primary perceived benefit of the camp experience.

Conclusions

Fun is a byproduct of coming to camp, but not the primary reason parents send their kids to burn camp. The robust survey response rate suggests that parents are eager to share their thoughts about the impact of camp. The detailed responses demonstrate an understanding of and appreciation for the specific social and emotional benefits of this unique shared experience. Finding congruence between the rationale for camp attendance, and the perceived benefits is conducive to optimal program planning.

Applicability of Research to Practice

Although it is not possible to undo any traumatic events suffered by a child, research on burn camps has elucidated the benefits primarily through a qualitative lens. The burn community continues to be challenged in validating the benefits of camps quantitatively. Motivating people to engage in specific behaviors, like attending an event, is a crucial step for delivering aftercare programs designed to help their recovery. Burn camps can offer a safe environment, connection with others who understand, and the possibility for long term positive relationships with trusted adults to potentially mitigate the impact of a medical trauma. Further research about the impact of such programs on trauma healing is warranted.
585 Preventing Occipital Pressure Injuries in Patients Admitted to the Burn ICU
Authors: Kammin Vitina M , Eckert Kristine , Alem Paula , Dimler Margaret A , Kammin Vitina M , Marano Michael
Published: March 2020

Introduction

Occipital pressure injuries (OPI) are categorized as pressure injuries on the occipital bone caused by pressure, shearing, or friction. Patients with significant burns are at a greater risk of developing these types of injuries due to increased fluid volume from resuscitation, decreased tissue perfusion, immobility, edema and length of stay. The rate of OPI in the BICU was 4.3 in 2016; this led to a comprehensive program to reduce/eliminate these injuries.

Methods

Early identification of at-risk patients and implementation of prevention strategies was conducted. Best practices were reviewed and the following interventions were put into place: on admission, all patients with facial burns, (intubated or not), were given a small size fluidized positioner pillow. The pillow was to be positioned with a defined divot in the center and not flattened (which is the way they were currently being utilized). The fluidized pillow must go into the hydrotherapy room with the patient and the patient’s head turned and repositioned every 2 hours. The use of a moisture-wicking fabric was utilized over the fluidized positioner pillow to prevent maceration. Nursing staff and burn technicians were educated as to practice changes; wound care nurses were available for educational support. In addition, in 2017, the Burn ICU instituted a 2 RN skin check daily for all patients in the hydrotherapy room once all dressings were removed. This tank room “time out” was instituted for early identification of areas of potential skin breakdown.

Results

Implementation of these protocols has significantly decreased the occurrence of OPI in the BICU. Since implementation, the rate of OPI in 2017, 2018 and Q1 and Q2 of 2019 has been 0%. The application of the fluidized positioner pillow, tank room “time-out” and staff education has greatly decreased the occurrence of OPI in the BICU.

Conclusions

Patients sustaining large surface area burns and/or full-thickness burns to the head and neck are susceptible to the development of OPI. The utilization of a fluidized positioner pillow in conjunction with improved assessment and identification using a 2 RN “time out” skin assessment daily, has led to a decrease in OPI in our BICU.

Applicability of Research to Practice

The utilization of the fluidized positioner pillow in conjunction with the described interventions can lead to a decrease in occipital HAPI and improve patient outcomes.