bluuebunny/crossref_metadata_2025 huggingface dataset:
Electrochemical contrast switching between black and white appearance of gelatin-covered zinc
Authors: Ksiazkiewicz Agnieszka Natalia , Fernández-Solis Christian , Erbe Andreas
Published: March 2020

Zinc and its alloys are widely used in the surface protection of metallic structural materials. Thus, zinc is an interesting and relevant candidate material for preparing stimuli-responsive surfaces. In this work, the switching of the optical appearance of zinc between black and white by an applied electrode potential is demonstrated. The zinc surface was covered by gelatin films and subjected to cyclic voltammetry (CV) in a chloride-containing electrolyte which induced pitting corrosion on the zinc surface. Between the different parts of the CV cycles, a reversible change in optical appearance was observed. During the oxidative half-cycles, the surfaces appear white, and during the reductive half-cycles, the surfaces appear brown to black, i.e. dark. Surface characterisation by x-ray photoelectron spectroscopy (XPS) and infrared (IR) spectroscopy shows that the gelatin coating is slightly oxidised during intial stages of the process, but remains intact and present at the surface. Raman spectra prove the presence of ZnO at the interface. Surface analysis shows only minor differences in composition between the black and white surfaces. Based on the available characterisation data, the white appearance associated with anodic currents is attributed to the formation of a non-passivating ZnO. The black appearance associated with cathodic currents is attributed to reduction of surface-confined zinc species, including ZnO and Zn2+. The role of the gelatin is presumably to prevent diffusion of the dissolution products into solution by complex formation and by acting as a diffusion barrier; gelatin will also affect the morphology of the reduction products. A similar switching was observed when gelatin was added to chloride electrolyte; surface analysis showed gelatin adsorption in this case. The black/white switching may, e.g. be useful for surfaces self-indicating corrosion potentials of galvanised steel.
Efficient machine-learning based interatomic potentialsfor exploring thermal conductivity in two-dimensional materials
Authors: Mortazavi Bohayra , Podryabinkin Evgeny V , Novikov Ivan S , Roche Stephan , Rabczuk Timon , Zhuang Xiaoying , Shapeev Alexander V
Published: March 2020

It is well-known that the calculation of thermal conductivity using classical molecular dynamics (MD) simulations strongly depends on the choice of the appropriate interatomic potentials. As proven for the case of graphene, while most of the available interatomic potentials estimate the structural and elastic constants with high accuracy, when employed to predict the lattice thermal conductivity they however lead to a variation of predictions by one order of magnitude. Here we present our results on using machine-learning interatomic potentials (MLIPs) passively fitted to computationally inexpensive ab-initio molecular dynamics trajectories without any tuning or optimizing of hyperparameters. These first-attempt potentials could reproduce the phononic properties of different two-dimensional (2D) materials obtained using density functional theory (DFT) simulations. To illustrate the efficiency of the trained MLIPs, we consider polyaniline C3N nanosheets. C3N monolayer was selected because the classical MD and different first-principles results contradict each other, resulting in a scientific dilemma. It is shown that the predicted thermal conductivity of 418 ± 20 W mK−1 for C3N monolayer by the non-equilibrium MD simulations on the basis of a first-attempt MLIP evidences an improved accuracy when compared with the commonly employed MD models. Moreover, MLIP-based prediction can be considered as a solution to the debated reports in the literature. This study highlights that passively fitted MLIPs can be effectively employed as versatile and efficient tools to obtain accurate estimations of thermal conductivities of complex materials using classical MD simulations. In response to remarkable growth of 2D materials family, the devised modeling methodology could play a fundamental role to predict the thermal conductivity.
A bound on the primes of bad reduction for CM curves of genus 3
Authors: Kılıçer Pınar , Lauter Kristin , García Elisa Lorenzo , Newton Rachel , Ozman Ekin , Streng Marco
Published: March 2020

We give bounds on the primes of geometric bad reduction for curves of genus

3
3

of primitive complex multiplication (CM) type in terms of the CM orders. In the case of elliptic curves, there are no primes of geometric bad reduction because CM elliptic curves are CM abelian varieties, which have potential good reduction everywhere. However, for genus at least

2
2

, the curve can have bad reduction at a prime although the Jacobian has good reduction. Goren and Lauter gave the first bound in the case of genus

2
2

.

In the cases of hyperelliptic and Picard curves, our results imply bounds on primes appearing in the denominators of invariants and class polynomials, which are important for algorithmic construction of curves with given characteristic polynomials over finite fields.
Reduced invariants from cuspidal maps
Authors: Battistella Luca , Carocci Francesca , Manolache Cristina
Published: March 2020

We consider genus one enumerative invariants arising from the Smyth-Viscardi moduli space of stable maps from curves with nodes and cusps. We prove that these invariants are equal to the reduced genus one invariants of the quintic threefold, providing a modular interpretation of the latter.
Correlations of multiplicative functions along deterministic and independent sequences
Authors: Frantzikinakis Nikos
Published: March 2020

We study correlations of multiplicative functions taken along deterministic sequences and sequences that satisfy certain linear independence assumptions. The results obtained extend recent results of Tao and Teräväinen and results of the author. Our approach is to use tools from ergodic theory in order to effectively exploit feedback from analytic number theory. The results on deterministic sequences crucially use structural properties of measure preserving systems associated with bounded multiplicative functions that were recently obtained by the author and Host. The results on independent sequences depend on multiple ergodic theorems obtained using the theory of characteristic factors and qualitative equidistribution results on nilmanifolds.
2 Impact of Multimodal Analgesia on Critically Ill Burn Patients
Authors: Young Sierra R , Duby Jeremiah , Louie Erin
Published: March 2020

Introduction

Opioids are considered the cornerstone of treatment for post-operative burn pain. However, detrimental adverse effects of opioid use include over-sedation, respiratory depression and dependence. Multimodal analgesia is an alternative method of pain control that utilizes a combination of opioid and non-opioid medications. Multimodal analgesia offers different mechanisms of action which may be beneficial in burn-injured patients. This study examines the impact of multimodal therapy for post-operative pain control in a burn intensive care unit (BICU).

Methods

This retrospective cohort study was performed at an academic burn center between 2012 and 2018. Consecutively admitted patients with burns greater than or equal to 10% total body surface area (TBSA) and BICU length of stay (LOS) greater than seven days were eligible for inclusion. Patients were excluded if they received an opioid continuous infusion greater than 48 hours. Patients treated with multimodal analgesia were compared to those treated with opioids alone. The total oral morphine equivalent (OME) dose was calculated for each 24-hour period for 5 days after a grafting surgery. Secondary endpoints included pain scores, BICU LOS, and ventilator days. Data analysis was performed with descriptive statistics. A power calculation determined that 60 patients per group were needed to detect a 30% difference in the primary endpoint.

Results

There were 100 patients in the non-multimodal group and 100 patients in the multimodal group. Mean cumulative OME dose was significantly lower in the multimodal group (1,028 mg vs. 1,438 mg, P < 0.002). Patients with over 20% TBSA burns had a larger reduction in mean OME doses in the multimodal group (1,097 mg vs. 1,624 mg, P = 0.0049) compared to patients with 10% to 20% TBSA burns (949 mg vs 1,282 mg, P = 0.057). Utilizing more multimodal agents was not associated with lower OME doses. There was no difference in pain score on post-operative day 5 (5.5 + 2.3 vs. 6.2 + 2.2, P=0.07) or at ICU discharge (4.7 + 2.4 vs 4.7 + 2.8, P = 0.99). There was no difference in other secondary outcomes.

Conclusions

The use of multimodal analgesia significantly reduced cumulative OME doses without compromising pain control.

Applicability of Research to Practice

Multimodal analgesia may be a beneficial adjunct to burn pain management to mitigate opioid use without compromising pain control.
5 The Predictive Capacity of ASA PS in Burn Patients
Authors: Choi Katherine J , Pham Christopher H , Collier Zachary J , Mert Melissa , Ota Ryan K , Li Ruibei , Yenikomshian Haig A , Gillenwater Justin , Kuza Catherine
Published: March 2020

Introduction

The four main prognostic models used to determine risk of burn mortality are the revised Baux (rBaux), Belgian Outcome in Burn Injury (BOBI), Abbreviated Burn Severity Index (ABSI), and quick Sequential Organ Failure Assessment (qSOFA). These models fail to factor in medical comorbidities. The ASA PS (American Society of Anesthesiologists Physical Status) is a simple scale incorporating severity of traumatic injury with comorbidities, which strongly predicts mortality in surgical patients. The purpose of this study is to determine whether the ASA PS is an adequate adjunct to measure burn severity.

Methods

All adults admitted to an ABA verified burn center from January 2016 to April 2019 with TBSA ≥10% who underwent surgery were reviewed. Demographics (age, gender, TBSA, race, ASA PS), vital signs (GCS, blood pressure, respiratory rate), and outcome variables (length of stay [LOS], mechanical ventilation [MV] days, and complications) were evaluated. rBaux, BOBI, ABSI, and qSOFA scores were calculated. The primary outcome was in-hospital mortality. After descriptive statistical analysis, mortality associations of the models were assessed by determining odds ratios. Firth’s logistic regression and area under the receiver operator curves determined the predictive utility of the prognostic scores.

Results

Of the 183 patients who fit inclusion criteria, median age was 44 years (30–57), and the majority (70%) were male. Median TBSA was 20%, 65% (n=118) had full thickness burns, 14% (n=25) had inhalation injury, and mortality was 9% (n=17). rBaux score was the best predictor of mortality (AUC=.84), ICU LOS (R2=.04), and MV days (R2=.06). For every 10-point increase in rBaux score, there was a 1.7 times increase in mortality (OR=1.7, CI 1.4–2.3, p< .00). The predicted ICU LOS increases from 2.8 to 31.4 days for the lowest and highest rBaux score quartiles. Compared to rBaux scores of 30–53, patients with scores of 54–70 had 4 times more MV days (CI 1.5–11, p< .00). The ASA PS was slightly inferior to rBaux in predicting mortality (AUC=.72), although not statistically significant (p=0.1). As ASA PS score went from I/II to III, III to IV, and IV to V/VI; mortality increased by 2.8 (OR=2.8, CI 1.5–5.5, p< .00).

Conclusions

rBaux is the best predictor of mortality, ICU LOS, and MV days although ASA PS also predicts mortality. Future studies should determine the combined predictive ability of ASA PS and rBaux.

Applicability of Research to Practice

rBaux and ASA PS scores can be used to determine risk of mortality in burn patients.
14 Do Calorie Counts Alter Care or Outcomes in Burn Patients?
Authors: Shepler Amanda , Fagert Kayleigh , Cochran Amalia , Coffey Rebecca
Published: March 2020

Introduction

Calorie counts are often used as a monitoring tool for burn nutrition and require accurate documentation by staff for the nutritionist to properly evaluate and treat the patient. The objective of this project was to determine if completion of calorie counts positively impacts patient outcomes.

Methods

A quality improvement project was conducted on adult burn patients at a large academic medical center from June 2018 to March 2019. All burn patients with calorie count orders and an admission weight were included. The total number of meal trays with completed calorie count documentation was calculated on a weekly basis, generating a total weekly calorie count compliance rate (CCCR). Data collected included weight change from admission to discharge, standard nutrition labs, and if nutritional interventions were changed.

Results

A total of 76 adult burn patients with a documented admission weight were included. The average total body surface area (TBSA) burn injury was 10.9%. Average length of stay was 1.3 days/ %TBSA. Of the 9.2% of patients with admission and discharge weights, 14% had increased discharge weight (mean CCCR 43%) and 86% had a decrease in weight (mean CCCR 48%). Weekly total protein levels were obtained in 24 patients with 46% having decreased total protein levels (0.1 to 1.1 g/dL) and a mean CCCR of 74.4%. Eight percent had no change in protein levels with a mean CCCR of 74.3% and 46% had increased total protein levels (0.1 and 0.7 g/dL) with a mean CCCR of 70%. Weekly albumin levels were obtained in 25 patients. Fifty-two percent had decreased albumin levels (0.1 to 0.9 g/dL) with a mean CCCR of 72.1%. Twenty percent had no change in albumin level, with a mean CCCR of 75.1% and 28% of patients had increased albumin levels (0.1 to 0.6 g/dL) with a mean CCCR of 69%. Weekly prealbumin serum levels were obtained in 27 patients. Fifty-six percent had decreased levels (1 to 19 mg/dL) with a mean CCCR of 74.1%. Four percent had no change in serum prealbumin, with a mean CCCR of 69%, and 41% had increased prealbumin levels (1 to 21 mg/dL) with a mean CCCR of 68%. Nutritional therapy was altered in 6% of patients by addition of oral supplementation, dietary modifications, or initiation of tube feeding.

Conclusions

A very small number of patients on calorie counts had any change in nutritional therapy and calorie count compliance showed no relationship with nutrition labs. However, calorie counts are labor-intensive for nursing staff. Further research should be conducted to identify which patients would benefit from daily calorie counts in the burn patient.

Applicability of Research to Practice

Use of evidence-based outcome measures can drive clinical practice.
16 Clinical Outcomes in Patients with Diabetes, Prediabetes, and No Diabetes Following Acute Burn Injury
Authors: Coffey Rebecca , Zhelezny Richard V , Porter Kyle , Zhang Charles , Murphy Claire V
Published: March 2020

Introduction

Based on the National Burn Repository Data (2002–2011), the incidence of diabetes is increasing among adult patients with burn injury. Diabetes has been associated with increased morbidity and mortality following burn injury. There is limited data related to prediabetes in burn injury, and no studies to date have compared clinical outcomes in patients without diabetes, with prediabetes, and with diabetes. Therefore, this study aimed to compare the impact of diabetes status, defined as no diabetes (ND), prediabetes (PD), or diabetes (DM), on clinical outcomes after burn injury.

Methods

A single-center, retrospective cohort study of adult patients admitted for initial management of burn injury between January 1, 2009 and February 28, 2019 who had a hemoglobin A1c (HbA1c) upon admission was performed. Patients with chemical or electrical injury, isolated smoke inhalation injury, total body surface area (TBSA) burn injury < 1%, patients who expired or transitioned to comfort care within 24 hours of admission, or were incarcerated or pregnant were excluded. Patients were categorized as ND, PD, or DM based on their past medical history and admission HbA1c. The primary outcome was LOS/%TBSA burn. Secondary outcomes included mortality, LOS, discharge disposition, re-grafting of same site, and amputations. Propensity score methods were used to account for imbalance between groups. Separate propensity score weights were calculated for analysis of DM versus ND and DM versus PD. The primary outcome LOS/%TBSA burn was compared between groups using weighted linear models. Since the outcome was right-skewed, LOS/%TBSA burn was log-transformed for analysis, yielding estimates of the ratio of geometric means.

Results

A total of 1137 patients were included (710 ND, 191 PD, 236 DM). Patients were predominately male (70.3% ND, 67.4% PD, 70.2% DM) and Caucasian (85.5% ND, 73.8% PD, 82.1% DM). The mean BMI was highest in DM (31.8 kg/m2) and lowest in ND (27.8 kg/m2). After inverse probability weighing to adjust for potentially confounding factors, DM had longer LOS/%TBSA burn than patients with ND (ratio of geometric means (95% CI) = 1.61 (1.21, 2.15), p = 0.001) or PD (ratio (95% CI) = 1.53 (1.14, 2.05), p =0.01). No differences in secondary outcomes were observed between the DM and ND groups and between DM and PD groups with the exception of amputations (2.8% DM vs. 0.7% ND, p=0.06; 2.6% DM vs. 0% PD, p=0.04).

Conclusions

Diabetes in the burn patient significantly increases LOS/%TBSA index and amputation rates compared to both PD and ND.

Applicability of Research to Practice

Diabetes may contribute to increased cost of care in burn injury. Early identification of diabetes status may aid management of this patient population.
19 Epidemiology of Acute Burn Admissions at a Referral Center in Nepal: A Comparison Between Direct Admissions and External Referrals
Authors: Mehta Kajal , Stewart Barclay T , Pham Tam N , Nakarmi Kiran K
Published: March 2020

Introduction

Nepal is a low-income country where burn injury is a leading cause of preventable deaths and disabilities. A major burn center was established in 2013 to care for patients with acute injuries and reconstruction needs from local and from distant communities. We aimed to characterize the epidemiology of admissions and patterns of referral to guide health system planning and efforts.

Methods

We described prospectively collected data from patients with acute burns from January 2016 to July 2019. Sociodemographic and injury data included age, sex, hospital of provenance or direct admission status, total burn surface area (TBSA), and presence of complications on admission (e.g., wound infection, sepsis). Outcomes included length of stay and mortality. Differences in proportions and medians were compared with Chi square and Wilcoxon Rank Sum tests, respectively.

Results

There were 1,813 patients admitted with acute burns over the study period. Median patient age was 26 years (IQR 12–45). More than half of patients were female (55%). Median TBSA was 15% (IQR 7–30%) with a median Baux score of 48 (IQR 27–75). Most patients were transferred from another facility (65% of admissions). Referrals came from over 300 facilities across the country. Referred patients had larger TBSA (median 16%, IQR 9–30%) compared to directly admitted patients (median 12%, IQR 5–30% (p=0.0001). Although median day post-burn day of presentation was 1 day for both groups, referrals had significant admission delays (IQR 0–7) compared to direct admissions (IQR 0–4, p=0.0001). An infection was present on admission in 5% of referrals compared to 2.4% of direct admissions (p=0.01). Median length of stay (among survivors) was longer for referrals (10 days, IQR 5–17) compared to 6 days (IQR 2–12) for direct admissions [p=0.001]). Mortality rate was relatively unchanged across the study period (23% in 2016, 21% in 2019, p=0.82). For patients with burn TBSA >40%, inpatient mortality decreased from 76% in 2016 to 51% in 2019 (p=0.05), however there were few instances of hospital discharges with a palliative intent. There was no difference in mortality rate for referrals compared to direct admissions (21 vs 22%, p=0.63].

Conclusions

Despite significant delays in presentation and higher rates of infection on admission, mortality for referral patients was similar to directly admitted patients. Additionally, improvements in care quality have led to significant decreases in the mortality rate for large burns. These data suggest that regionalization of care in Nepal may successfully rescue and manage severe burns in a specialized center.

Applicability of Research to Practice

These data support regionalization of care for patients with burn injuries in Nepal. Further work to understand the epidemiology and care of patients who do not get referred is required to address system gaps.
20 The Global Burn Registry: A Work in Progress
Authors: Gibson Cameron J , Bessey Palmer Q , Gallagher James
Published: March 2020

Introduction

In 2018 the World Health Organization (WHO) launched the Global Burn Registry (GBR). Its purpose is to help improve the understanding of burn injury worldwide. The purpose of this study was to identify early findings from this database.

Methods

The GBR was accessed in September 2019. Cases from centers in low income (LIC) and low-middle income countries (LMIC) were combined into a Low Resource (LR) group, and cases in High Income (HIC) and Upper Middle Income (UMIC) countries were combined into a High Resource group (HR). Statistical analysis was performed with SAS 9.4. Data are expressed as mean ± SEM. Logistic Regression was used to identify risk factors for death. Revised Baux Score (RBS) was calculated as described by Osler (2010). Odds ratios are expressed as mean (95% confidence interval). The LA50 was calculated from the regression of death and total burn size (TBSA) for different age groups.

Results

At the time of analysis, there were 2,315 cases in the GBR treated at 23 facilities in 15 countries (4 HIC, 5 UMIC, 4 LIMC, and 2 LIC). There were 1,346 cases (58%) from HR countries and 969 (42%) from LR countries. The patients in LR were older than those in HR (26.2 ± 0.6 years vs 20.7 ± 0.6, p< 0.01) and had larger TBSA burns (31.0 ± 0.8 % TBSA vs 16.6 ± 0.4, p< 0.01). There were fewer scald burns and more flame injuries in the LR countries (26 ± 1.4 % vs 54 ± 1.4, and 56 ± 1.6 % vs 32 ± 1.3, p< 0.01). Case fatality and RBS were greater in LR (31.5 ± 1.5 % vs 4.8 ± 0.6 and 61.4 ± 1.3 % vs 38.9 ± 0.9, p< 0.01). In regression analysis, LR was an independent risk factor for death with an odds ratio of 6.3 (4.3 – 9.4). The LA50 for HR countries was similar to those in the National Burn Repository. For LR countries the LA50 was lower for all ages except those 65 and older, ranging from 30–45% TBSA.

Conclusions

Only a few facilities have contributed data to the GBR so far, with lower resourced countries less represented than higher resourced ones. The proportion of cases in the pediatric age group is much less represented in LR countries than in HR, possibly because many burned children in LR countries do not get burn care at specialized centers. Survival in HR countries is similar to that in North America. The GBR provides early insights into global burn care. Opportunities for improvement are greatest in LR countries. New Innovations may be necessary to increase participation from burn centers in LR countries.

Applicability of Research to Practice

This report provides an early look at burn care across the globe based on cases in the GBR. It may inform further efforts to characterize and improve burn care in low resourced countries.
30 Does Peer Support Facilitate Social Integration Following Burn Injury?
Authors: Holavanahalli Radha K , Roaten Kimberly , Sanchez Adriana
Published: March 2020

Introduction

Facilitating access to one-to-one peer support is an important criterion in providing aftercare for individuals with a burn injury. Although there is an increase in understanding of the perceived benefits of peer support, there are not many studies examining peer support as an intervention to promote community re-entry. This comparative study aims to examine if there is a difference in physical and mental health outcomes, including social reintegration between a group that received one-to-one peer support (PS) and a group that did not receive the peer support (NPS).

Methods

Subjects include adults (>=18y) with a major burn injury who received treatment at a major burn center and consented to participate in a longitudinal national database at discharge from hospital, 6-, 12-, and 24-months post injury. The physical and mental health outcomes were measured using the SF-12 Health Questionnaire – Physical (PCS) and Mental (MCS) component (50 is the average score or norm); the Satisfaction with Life Scale, and Social Integration (SI) was measured by the Community Integration Questionnaire Social Component Scale (score range 0–12; 0 is no community integration and 12 is excellent community integration). The PS program offered at the burn center is a standardized program that includes an 8-hour peer volunteer training. Independent Samples t Tests were conducted to see if there were significant differences in health outcomes between the group that received PS and the group that did not receive PS (NPS).

Results

Over a period of 5 years, 228 subjects consented to participate in the database. Subjects were predominantly male (70%) and White (72%), with a mean age of 44 years and the mean total body surface area was 24.8%. Sixty-three (28%) subjects received peer visits during their stay in the hospital. Compared to the NPS group, the social integration score for the PS group was higher at all time points, although it was statistically significant only at 24 months (PS= 8.22, NPS=7.13, p< .01). The PS group scored significantly higher in satisfaction with life at 6 months (p< .01) and at 12 months (p< .05). There were significant differences found in TBSA %burn (PS = 31%, NPS = 22%; p< .001), average length of acute hospital stay (PS= 52 days, NPS = 31 days; p< .01), and average length of in-patient rehabilitation stay (PS= 12 days, NPS = 5 days; p< .05).

Conclusions

The social integration and satisfaction with life scores of the PS group was higher when compared to those of the NPS group. The study highlights the profile of patients who seek peer support visits and has implications for delivery and utilization of burn aftercare programs.

Applicability of Research to Practice

The study findings highlight the emerging need for providing burn survivors with resources such as peer support to facilitate successful community reentry, and examine the effects of such interventions on health outcomes.
48 Burn Injury Impedes Late Erythropoiesis via Decreased Alpha Hemoglobin Stabilizing Protein and siglec1
Authors: Muthumalaiappan Kuzhali , Walczak Julia , Johnson Camargo , Bunn Corinne
Published: March 2020

Introduction

Transfusions are of no benefit to burn patients with chronic anemia. We are elucidating the mechanisms of erythropoietin resistant anemia in burn injury using a mouse model in addition to a contrived system with human PBMCs. We have found that Alpha Hemoglobin Stabilizing Protein (AHSP), an erythroblast specific protein essential to effective hemoglobinization, is decreased in PBMC derived erythroblasts (EB) from burn patients (male + female). Hemoglobinization begins at the polychromatic EB (PolyE) stage and intensifies at the orthochromatic EB (OrthoE) stage, culminating in ejection of the nucleus and the cell becoming a reticulocyte (Reti). EB needs the support of a central island macrophage (EBI MØ) until they progress to maturation. We have seen in bone marrow from mice (male) following burn injury that Siglec1, an essential adhesion molecule is decreased in EBI MØ. It is these MØ that provide iron for the assembly of the hemoglobin unit in late erythropoiesis. EB maturation defects seen in burn injury could be due to the intrinsic changes in EB phenotype or the phenotype of supporting EBI MØ or a combination of the two. Our goal was to investigate in the animal model using male and female mice, how myeloid/erythroid intrinsic changes after burn impact the progression of late erythropoiesis from an EB and EBI MØ perspectives.

Methods

With IACUC approval, 12 male and female mice were anesthetized and subjected to sham burn or scald burn (15% TBSA) upon dorsal immersion in a 100oC water bath for 8 seconds. Animals were sacrificed on post burn day 7 (PBD 7). Total bone marrow cells (TBM) were harvested from bilateral femurs. Cells were characterized using CD71, Ter119, and Syto16 antibodies. EBI MØ were identified using a combination of F4/80, ERHR3, Vcam1, Ly6G and Siglec 1 antibodies. Geometric mean of fluorescence intensity (MFI) and cell counts were obtained by flow cytometric analysis and presented as x103 per million TBM cells. Peripheral blood was harvested via cardiac puncture and hemoglobin concentrations (g/dL) were obtained using a hematology analyzer.

Results

Among the erythroblasts, EEBs were 2.4 fold higher with a 2.4 fold lower AHSP expression in PBD 7 mice compared to sham as shown in left, top and bottom figures. Similarly, more EEBs were associated with EBIMØ with a lower Siglec1 expression as shown in right, top and bottom figures. Blood Hbg concentrations were lower in burn (sham=15.5±0.7 vs PBD 7= 13.1±0.5; p< 0.01).

Conclusions

The combined influence of Siglec1 and AHSP expression interferes with effective hemoglobinization impeding late maturation of erythroblasts following burn injury. Whether there is a synergistic action between the two deficiencies is being studied.

Applicability of Research to Practice

Underpinning the mechanism of erythropoiesis will lead to better options to ineffective transfusions in burn patients with anemia.
50 Assessment of Skin Graft in Pediatric Burn Patients Using Machine Learning Is Comparable to Human Expert Performance
Authors: Ribeiro Guilherme Aramizo , Ridelman Elika , Klein Justin D , Angst Beth A , Shanti Christina M , Rastgaar Mo
Published: March 2020

Introduction

Though widely used, current scar assessment scales are inaccurate and highly subjective, further complicating the already difficult task of determining the optimal management of burn patients. Additional disadvantages of these tools include the need for direct examination by an experienced clinician and the inability to retrospectively review them. The lack of an accurate assessment tool inevitably impairs any research examining novel therapeutic strategies designed to improve burn scar outcomes by introducing observer bias at every step. Common examples of these tools include the Vancouver Scar Scale and Visual analog scale. New imaging and processing technologies have the potential of bringing accuracy, reproducibility, and accessibility to burn scar assessments. With these goals in mind, our team developed a novel scoring system and a classification model based on Machine Learning algorithms and analyzed 87 pictures to obtain scores on Inflammation (I), Scar (S), Uniformity (U), and Pigmentation (P).

Methods

All algorithms were trained using both the sub-acute and the long-term phase pictures. The classification model is based on supervised learning, which requires many examples of annotated pictures and corresponding scar scores. The model used a Linear Discriminant Analysis (LDA) algorithm and visual features of the scars and the natural skin. To train and evaluate this model, four burn care providers individually annotated 186 pictures of skin grafts and later formed a committee to annotate by consensus a subset of representative pictures. While the individual predictions were used as an accuracy baseline, the consensus annotation was the true score and used to train the model.

Results

The model predictions were more accurate in scores mainly based on color (I and P), rather than texture (S and U), as shown by the micro-averaged Area Under the Curve (AUC) of 0.86, 0.61, 0.51, and 0.80 for I, S, U, and P, respectively (Figure 1). The model accuracy was higher than the human baseline for the I (F1 of 0.60 vs. 0.59±0.13, respectively) and P scores (0.54 vs. 0.51±0.09), but lower in the S (0.30 vs. 0.63±0.22) and U scores (0.62 vs. 0.86±0.19).

Conclusions

Our findings are encouraging and suggest that further improvement of the accuracy of the algorithm could be achieved on the second phase of our assessment development project by increasing the number of pictures it learns from and adding more visual features related to skin texture.

Applicability of Research to Practice

Our study provides an accurate and reproducible evaluation of burn scars, that leads to newer therapeutic strategies employed by specialized burn care facilities.
51 Negative Pressure Wound Therapy for Small-to-medium-sized Paediatric Thermal Burns: A Randomized Controlled Trial (SONATA in C)
Authors: Frear Cody , Griffin Bronwyn R
Published: March 2020

Introduction

In the setting of burns, negative pressure wound therapy (NPWT) has been widely adopted as a means of wound bed preparation prior to skin grafting and graft immobilization. Its role in the treatment of acute burns has been less well-studied, although there is limited evidence to suggest that it might facilitate physiological healing. This study aimed to assess its efficacy in the management of acute burns in children with small-to-medium-sized thermal injuries.

Methods

In this single-center, two-arm, parallel, randomized, controlled clinical trial, we assigned patients under 17 years of age with acute thermal burns covering < 5% of their total body surface area to either an active control (nanocrystalline silver dressings) or an experimental treatment combining standard dressings with NPWT. Patients were excluded if their burn occurred >7 days prior to presentation, affected the face, or was deemed by clinicians to be trivial. The primary outcome was time to re-epithelialization. Secondary outcomes included scarring, grafting, pain, ease of management, and adverse events.

Results

A total of 114 children underwent randomization. The median time to re-epithelialization was 8 days (interquartile range (IQR) 7–10) for the NPWT group and 10 days (IQR 8–12.25) for the control group (hazard ratio, 1.515; 95% confidence interval (CI) 1.003 to 2.289; P=0.048). Children administered NPWT within 48 hours of their injury (n=16) re-epithelialized in a median of 7 days (IQR 5–8; HR, 2.129; 95% CI 1.155 to 3.922; P=0.015). The proportion of children referred to scar management was 8.7% for the experimental group and 25.9% for the control group (odds ratio, 0.27; 95% CI 0.08 to 0.90; P=0.032). There were no significant differences in grafting (2.2% vs. 7.4%; odds ratio, 0.28; 95% CI 0.03 to 2.58; P=0.260), pain during dressing changes (P=0.946), or at-home pain between dressing changes (P=0.592). NPWT was associated with a greater treatment burden (P< 0.001) and incidence of adverse events, which included minor blistering and wound maceration.

Conclusions

In children with small-to-medium-sized thermal burns, NPWT accelerated re-epithelialization and decreased the need for long-term scar management.

Applicability of Research to Practice

This study found NPWT to be a promising adjunct to standard care in the treatment of pediatric thermal burns. (Clinical Trials Registry number, ACTRN12618000256279.)
52 Developing a Topical Antibiogram in the Burn Unit
Authors: Robinson Andrew D , Walroth Todd A , Spera Leigh J , Sood Rajiv , Hartman Brett , Cheatham Megan , Relich Ryan
Published: March 2020

Introduction

Antibiograms display susceptibilities based on bacterial growth in response to systemic agents, utilizing automated systems performing bacterial identification and susceptibility testing. There is a paucity of literature regarding burn-specific antibiograms or susceptibility testing of organisms isolated from wound cultures against topical antimicrobials. Our goal was to create an institutional topical antimicrobial antibiogram in burn and dermatologic disorder patients.

Methods

Institutional topical antimicrobial agent susceptibilities were retrospectively reviewed from 1/1/18-12/31/18. Quantitative biopsies or swabs collected from patients were cultured. Susceptibility plates were prepared by wells aseptically punched into an agar plate and inoculated with antimicrobial creams. Bacterial isolates were then inoculated in melted agar, overlaid onto the susceptibility dish, and incubated. Zones of inhibition (ZOI) were reported in mm; susceptible being any measurable zone and resistant defined as a zone of 0 mm. Isolated organisms were grouped as Gram-positive cocci (GPC), Gram-negative rods (GNR), or yeast-like fungi (YLF).

Results

In 2018, 21 organisms were tested for susceptibility in 19 patients with positive cultures. Overall susceptibilities of isolates were 71–91%. Overall, susceptibility rates were: gentamicin 71%, mupirocin 77%, silver sulfadiazine 77%, and mafenide 91%. All C. albicans isolates were susceptible to nystatin. Excluding resistant isolates, the median (IQR) ZOI measurements were: gentamicin 10.0 (7.0, 15.0), mupirocin 12.0 (7.5, 27.0), silver sulfadiazine 8.0 (7.0, 10.5), and mafenide 14.5 (10.3, 19.8). Of organisms reported, there were 10 GNR (45%), 8 GPC (36%), and 4 YLF (18%), with P. aeruginosa, MRSA, and C. albicans being most common. For GPC, susceptibility rates were 63–88% and median (IQR) ZOI measurements were: gentamicin 16.0 (8.0, 30.0), mupirocin 27.0 (9.8, 35.5), silver sulfadiazine 10.0 (8.5, 19.0), and mafenide 15.0 (10.0, 22.0). For GNR, susceptibility rates were 70–90% and median (IQR) ZOI measurements were: gentamicin 10.0 (6.0, 11.0), mupirocin 12.0 (7.0, 18.0), silver sulfadiazine 7.5 (7.0, 9.5), and mafenide 15.0 (13.0, 19.0).

Conclusions

Based on susceptibility profiles of isolated organisms, mafenide appears to be an appropriate first-line empiric agent with an overall susceptibility rate greater than 90% and the largest ZOI amongst topical agents tested. When examining GPC, mupirocin demonstrated the largest ZOI and may be a more appropriate empiric choice if Gram-stain results are available.

Applicability of Research to Practice

To our knowledge, no previously published studies exist in burn patients examining susceptibilities to topical antimicrobials. These antibiogram-level data provide direction for empiric treatment of wound infections utilizing local susceptibilities for targeted topical coverage.
73 Objective Measurement of Adherence with Splint Use After Burn Injury
Authors: Parry Ingrid , Bastea Silvia , James Michelle , Greenhalgh David G
Published: March 2020

Introduction

The prescription of splints (orthoses) to help protect vulnerable structures and maintain range of motion after skin grafting is an integral and important part of burn recovery. The degree to which a patient adheres to wearing a prescribed orthosis is believed to play a major role in outcome. However, orthoses may be uncomfortable or undesirable to wear, affecting a patient’s adherence. At our burn center, orthosis application and wear is heavily dependent on staff when patients are in the ICU. As patients move to the acute ward, the responsibility for orthotic use is shared by family and staff and as outpatients, caregivers are primarily responsible. The purpose of our study was to use temperature sensors implanted in the orthoses to objectively determine compliance rates with splint wear during these three different stages of burn recovery.

Methods

Pediatric patients with skin grafting to the hands who were prescribed a hand splint had a temperature sensing device implanted into their orthosis when it was fabricated and prescribed for wear. The sensors detected higher temperatures when the orthosis was on the patient and lower temperatures when it was not, providing an objective means to determine frequency and duration of wear. The data collected for each patient was compared to the prescribed time as noted in the medical record by the treating therapist. Data was analyzed using descriptive statistics and one-way ANOVA.

Results

Data were recorded for an average of 50 days for 12 patients using 17 splints during three continuous phases of care: ICU, acute ward, outpatient. Patients in ICU wore their splints 10.4 hours per 24 hour period, resulting in a 102% hourly compliance based on the prescribed wear time. During acute ward care, patients wore their splints for 7.6 hours (89% hourly compliance). As outpatients, subjects wore their splints an average of 6.7 hours (82% hourly compliance). There was no statistical difference in orthotic adherence between the phases of care. Daily compliance (days worn/ days prescribed) showed a similar trend: ICU=100%, ward=90%, OP=88%. Patients or their caregivers were asked to rate their own adherence with splinting at 8 weeks after injury using a 1–4 Likert scale. All but one patient reported the highest level of compliance and described use “as instructed by therapist” (92%).

Conclusions

This is the first study to objectively measure patient adherence with wearing orthoses over the course of burn recovery. Results show high level of adherence in ICU but demonstrate declining adherence as the patient and caregiver assume more responsibility. This study highlights potential areas for improvement in patient education during transition of care from inpatient, and highlights the need for better understanding of the barriers that exist for long-term orthotic use after hospitalization.

Applicability of Research to Practice

Prevention of contracture with splints.
83 Multicenter Evaluation of the Use of Nebulized Heparin for Inhalation Injury (HIHI2 Study)
Authors: Cox Courtney , McIntire Allyson M , Bolton Kimberly , Foster David , Fritschle Andrew , Harris Serena , Pape Kate , Whitten Jessica , Hartman Brett , Sood Rajiv , Walroth Todd A
Published: March 2020

Introduction

Inhalation injury (IHI) causes significant morbidity and mortality secondary to local compromise of the respiratory system as well as systemic effects limiting perfusion and oxygenation. Nebulized heparin reduces fibrin cast formation and duration of mechanical ventilation in patients with IHI. To date, no study has compared both dosing strategies of 5,000 and 10,000 units to a matched control group. The objective of this study is to compare heparin 5,000 and 10,000 units to a historical control and determine which dosing strategy improves lung function and decreases mechanical ventilation duration.

Methods

This multicenter, retrospective, case-control study included adult patients with bronchoscopy-confirmed IHI. Each control patient, matched according to age and percent of total body surface area (TBSA), was matched to a patient who received 5,000 units and a patient who received 10,000 units of nebulized heparin, according to each institution’s inhalation injury protocol. Patients were excluded if they were pregnant, incarcerated, died within 72 hours of admission, terminally weaned for reasons other than burn or IHI, had a documented allergy to heparin or history of heparin-induced thrombocytopenia, history of pulmonary hemorrhage within 3 months, or history of a clinically important bleeding disorder. The primary endpoint of the study was total duration of mechanical ventilation (excluding patients who died or were not extubated). Secondary endpoints included 28-day mortality, ventilator-free days in the first 28 days, difference in lung injury scores, length of hospitalization, incidence of bronchoscopy, incidence of ventilator-associated pneumonia, and rate of bleeding events.

Results

Thirty-five matched patient trios met inclusion criteria. Groups were well-matched for age (p=0.975) and TBSA (p=0.855). When excluding patients who died or were never extubated, patients who received nebulized heparin, either 5,000 or 10,000 units, had 8–11 less days on the ventilator compared to controls (p=0.001). Mortality ranged from 3–14% overall, and no statistical difference was observed between groups. No major or minor bleeding events related to nebulized heparin were reported.

Conclusions

Mechanical ventilation days were significantly decreased in patients who received 5,000 or 10,000 units of nebulized heparin. There was no statistically significant difference in mortality between groups, supporting that either 5,000 units or 10,000 units of nebulized heparin should be used in IHI treatment.

Applicability of Research to Practice

To our knowledge, no previously published studies have simultaneously compared dosing strategies of 5,000 and 10,000 units to a control group. These results support the use of nebulized heparin for IHI to reduce the duration of mechanical ventilation.
96 Treatment of Donor Sites in Large TBSA Burn Injuries with an Autologous Skin Cell Suspension Supports Early Reharvesting
Authors: Foster Kevin N , Holmes James H , Hickerson William L , Shupp Jeffrey W , Sheridan Robert , Lee Jeanne , Rizzo Julie A , Short Tracee , Goverman Jeremy , Hartman Brett , Hodge Juvonda , Mullins Robert F , Litt Jeffrey , Huzar Todd F
Published: March 2020

Introduction

Treatment of large TBSA burn injuries is often limited by donor site availability and requires reharvesting to obtain definitive closure. Patients with severe injuries may have delayed closure compared to uncompromised patients that typically have their donor sites healed in 7–14 days.

Autologous skin cell suspension (ASCS) can be prepared to treat burn wounds at the point-of-care. The safety and effectiveness have not yet been established for use in the treatment of donor sites. This study presents the use of ASCS for the treatment of donor sites in patients with life-threatening burn injuries that were enrolled in a prospective uncontrolled observational study (IDE 15945—NCT02992249).

Methods

ASCS was applied to the donor site after harvesting of STSGs. Clinical outcomes out to one year were evaluated including percentage of re-epithelialization, long-term cosmetic outcomes, and adverse events.

Results

Ninety-six subjects from 22 burn centers had their donor sites treated with ASCS as part of their treatment regimen. The average subject age was 30.1 and the average TBSA injury was 53.7 ±17.3%. The mean Baux score was 89.2 with 36% of subjects having a score greater than 100. Collectively, 528 donor sites were individually treated.

In this compromised patient population 37.5% were ≥95% re-epithelialized by week 1 (n=435), and by week 2, 82.7% of the donor sites were ≥95% re-epithelialized (n=434), regardless of how many times they were harvested.

Approximately 19% of the donor sites treated with ACSC were reharvested multiple times following initial healing (15% two times, 2.3% three times, and 7 donor sites were harvested 4 times) and retreated. Of donor sites harvested more than once, 39.3% (n=84), 81% (n=79), and 85.7% (n=77) of sites were ≥ 95% re-epithelialized by week 1, 2 and 4, respectively.

One-year data was available for 427 donor sites and the majority had matched or mildly mismatched color, pigment, and texture. Adverse events included one site with a hematoma, one patient with donor sites that had fragile skin loss secondary to traumatic friction, one patient with active bleeding, two patients with anemia secondary to donor site bleeding, one patient with delayed closure due to mild infection of staph species. All AEs were unlikely or unrelated to the device.

Conclusions

ASCS has been successfully used to achieve closure of donor site wounds without significant safety risk in patients with extensive burn injuries.

Applicability of Research to Practice

Application of ASCS for donor site healing may be particularly relevant for patients with large burn injuries requiring subsequent reharvesting to achieve definitive closure.