bluuebunny/crossref_metadata_2025 huggingface dataset:
601 Bromelain Based Enzymatic Debridement Followed by Application of Autologous Cell Suspension for Treatment of Burns
Authors: Williams Ashley , Mbaka Maryann , Ledbetter Kate , Huett Wilson , Simmons Jon D , Bright Andrew
Published: March 2022

Introduction

Bromelain based enzymatic debridement has been shown to have a unique selectivity for nonviable tissue and is being evaluated for its use in the treatment of select burn wounds. The treatment has potential to augment more traditional operative eschar excision. Herein, we retrospectively review our tertiary burn center’s early experiences in cases in which bromelain based enzymatic debridement (BBED) is paired with autologous cell suspension (ACS).

Methods

Patients whose burn wounds were deemed eligible for BBED at our institution from July 2020 to June 2021 were queried for concurrent treatment with ACS. Inclusion criteria by study design consisted of 18 years of age or older, non-electrical and non-chemical burns, predominance of deep partial and/or full thickness burn, and less than 30% total body surface area. Success of escharotomy by BBED, grafting methods, infections, transfusions, inflammatory response, and response to grafting were analyzed.

Results

Seven patients met inclusions criteria from July 2020 to June 2021. The mean age was 44 (IQR: 39-53). The mean TBSA was 13.7% (IQR 8-20). The mean time from injury to BBED was 2.1 days (IQR 1.5-2.0). The mean time to ACS after BBED was 1.3 days (IQR 1.0-1.5). The mean area debrided with BBED was 2347 sq cm (IQR 1367-3534). All patients were determined to have complete eschar removal on the day of application by the multidisciplinary burn team. All seven cases had deep partial thickness areas treated with ACS alone, with a mean area of 1574sq cm (IQR 877-2327). The total area treated was 11,016 sq cm. Only two patients required delayed grafting, a combined total of 1573 sq cm, meaning that 86% of the total burn area treated with ACS alone was recovered. Five patients had ACS paired with split thickness autografts, with a mean area of 867 sq cm (IQR 519-1328). Graft imbibition was noted to be rapid with >95% wound closure by postoperative day eight. There were no graft infections, and no transfusions required. White blood cell (WBC) counts decreased after BBED, then increased marginally after grafting. Only two patients had WBC >20,000 and this aided in diagnosis of one donor site infection and one pneumonia.

Conclusions

In our series, BBED within three days of injury paired with ACS within two days of BBED resulted in excellent split thickness graft take and recovery of 86% of the burn wounds treated with ACS alone.
610 Myofibroblasts Are Not Characteristic Features of Keloid Lesions
Authors: Supp Dorothy M , Hahn Jennifer M , McFarland Kevin L , Combs Kelly A , Powell Heather
Published: March 2022

Introduction

Keloids are disfiguring, fibroproliferative lesions that can result from an abnormal wound healing process. Keloids are characterized by excessive and abnormal deposition of extracellular matrix and unrestrained expansion beyond the original wound boundary. Keloids are challenging to treat, with low response rates to current interventions and high recurrence rates. Development of more effective, targeted therapies will require a deeper understanding of the mechanisms driving keloid pathology. It has been widely reported that keloids are characterized by the presence of myofibroblasts, which are specialized, contractile fibroblasts that express alpha-smooth muscle actin (αSMA) and play important roles during wound healing and tissue remodeling. However, the evidence supporting a role for myofibroblasts in keloid development is inconclusive, with conflicting reports in the literature. This complicates development of more effective therapies, as the benefit of interventions targeting myofibroblasts is unclear. The current study evaluated the presence of αSMA+ myofibroblasts in keloids, and analyzed αSMA expression in keloid-derived fibroblasts, to determine whether myofibroblast presence can be considered diagnostic of keloid lesions.

Methods

Keloid, hypertrophic scar (HTS), and normal human skin samples were collected with Institutional Review Board approval and primary fibroblast cultures were established. Myofibroblasts in tissue sections were localized by αSMA immunostaining, and αSMA expression in pericytes of blood vessels was distinguished from αSMA+ myofibroblasts by collagen IV immunostaining of vessels. Expression of αSMA mRNA (ACTA2 gene) was measured using quantitative real-time PCR. Statistical analysis via t test was performed using SigmaPlot.

Results

Normal human skin samples did not exhibit αSMA+ myofibroblasts (0/8), but myofibroblasts were identified in 53% of keloids (8/15) and 60% of HTS (3/5) tissue samples. When present in keloids or HTS, the αSMA+ cells were not uniformly distributed, but were often observed in clusters in the deeper regions of the lesions. Comparison of ACTA2 mRNA expression did not reveal any significant differences between normal skin and keloid tissues (N=3/group), or between normal fibroblasts (N=7 donors) and keloid fibroblasts (N=9 donors).

Conclusions

The results suggest that although many keloids contain αSMA+ myofibroblasts, these cells do not appear to be diagnostic for keloids. Therefore, therapies that target myofibroblasts may not be effective for all keloid lesions. However, a limitation of this study is that only excised keloid and HTS tissues, which tend to be larger, more mature lesions, were examined; thus we cannot rule out a potential role for myofibroblasts in early development of abnormal scars.
618 Firefighter Resiliency Project: Survey Findings and Implications for a Program Model
Authors: Dillard Dana R , King Erin A , O'Dare Kellie , Rotunda Rob
Published: March 2022

Introduction

Firefighters are trained to respond to an array of acute emergencies that culminate in repeated exposure to trauma subsequently impacting their mental health. Yet, they often fail to seek services that could mitigate those adverse effects due to stigma, as well as a dearth of systematized resources and first responder proficient trained mental health professionals. This study explored work-related traumatic event exposure, PTSD symptomatology, levels of depression, anxiety, and suicide risk, and barriers to care for firefighters in a designated catchment area of a southeastern state. Results were used to inform local departments interested in culture change and intervention, as well as providing the basis for successfully obtaining federal grant monies.

Methods

Using Qualtrics, a web-based survey platform, researchers administered a cross-sectional survey to firefighters between Fall 2020 and Spring 2021. The survey included the PCL-5, PHQ-9, GAD-7, SBQ-R, and BACE. Descriptive statistics, correlations, and independent t-tests were run to determine the level of trauma exposure and clinically significant mental health symptomatology, associations between different types of trauma and mental health symptoms, and barriers to accessing care. The sample (N=511) primarily identified as Caucasian (n=421) and male (n=477). Mean age and time in fire service were 39.1 and 14.5 years, respectively.

Results

In this sample, 18.7% met the criteria for a provisional diagnosis of PTSD based on the PCL-5; 24.4% met the criteria for moderate to severe depression based on the PHQ-9; 14.5% met the criteria for moderate to severe anxiety based on the GAD-7; and 13.7% reported a significant risk of suicidal behavior as measured by the SBQR. Firefighters also indicated the following as the most common barriers to accessing care: 1) being unsure of where to get care (47.3%); 2) thinking the problem would get better itself (41.8%), 3) feeling embarrassed or ashamed (39%), 4) concern that they might be seen as weak for having a mental health problem (36.2%), and 5) thinking they did not have a problem (34.3%).

Conclusions

Due to the high levels of work-related trauma exposure, firefighters in this study were at an increased risk of developing mental health symptomatology including PTSD, depression, anxiety, and risk of suicidal behavior when compared to the general population. Additionally, perceived and actual barriers to care provided implications for the grant program application.
619 Pain Management in Burn and Wound Patients: Effects of Acupuncture in Pain Score and Medication
Authors: Lasso Erika Tay , Herekar Anjali , Riggle Clara , Li Sheng , Hwang Hui , Horie Mariko , Phelps Kenneth S , Burton Kimberly , Alaniz Leonardo , Hovis Gabrielle , Hecht Kim , Nunez Molly E , Joe Victor C , Chin Theresa L
Published: March 2022

Introduction

Pain management in burn patients is a complex ongoing problem. Opioid and non-opioid medications have historically been used as the primary pain management modality in burn care. Considering the ongoing opioid epidemic, a multidisciplinary holistic approach is needed for pain management. Acupuncture has been recognized to help in different settings such as chronic back pain, neurological problems, depression, and anxiety.

We hypothesize that burn and wound patients receiving acupuncture will have a decrease in opioids and non-opioid medications on acupuncture day (ACd) compared to non-acupuncture day (n-ACd) and a reduction of pain scores before and after acupuncture.

Methods

A prospective observational study in all patients admitted to the burn service was made. We exclude patients that were unable to provide consent or age 6 years and younger.

A numeric pain score (1-10) was collected from the patients before and after each acupuncture session; if patients were sleeping after acupuncture pain score was collected when they woke up. A prospective collection of daily opioids and non-opioids medications was made. Opioids were converted to daily morphine equivalents (MME).

Results

From February to August 2021, 53 patients on the burn service were treated with acupuncture for a total of 185 sessions. The median age was 49 years (IQR:32.5-63.0). Median TBSA for burn patients was 3.3% (IQR:1.5-8.1). The number of sessions per patient ranged from 1-12 with a median of 3 (IQR1.7-4). Before acupuncture, the median pain score was 5 (IQR:2.6-6.4), and after treatment was it was 1.5 (IQR:0.2-2.8).

Of 185 sessions, 49 (26%) of those sessions, patients fell asleep afterward. Median morphine use on ACd was 26.6 MME (15.8-62.1) vs. n-ACd 27.35 MME (15.5-65.3). For non-opioid medication, the median of acetaminophen on ACd 1007.5mg (313.39 -1950) vs. n-ACd 1381.25mg (642.5-2535).

After adjusting for TBSA and chronic opioid use, patients were given a daily mean of 391 MME CI: (1201.12-419.12 p=0.334) less in ACd vs. n-ACd. In addition, acetaminophen had a daily mean of 395.12mg CI: (130.05, 660.19 p=0.005) less in ACd vs. n-ACd.

Overall, acupuncture was associated with a significant lower pain score with a mean of 2.799 points less.

Conclusions

Acupuncture seems to abrogate pain in burn and wound patients, as demonstrated by doses of pain medication. While there was no significant difference in opioid medications, there was a significant difference in acetaminophen, indicating that additional education of a tiered approach to pain medications is essential to reduce unnecessary opioid use.
624 Implementation of a Collaborative Drug Therapy Management Protocol in an Adult Burn Clinic
Authors: Boyd Allison N , Walroth Todd A , Hartman Brett C
Published: March 2022

Introduction

Collaborative Drug Therapy Management (CDTM) protocols allow qualified clinical pharmacists working within a defined context to independently assume responsibility for a variety of direct patient care activities. The goal of this model is to improve access to care, often in a more affordable and timely manner. Pharmacists in our burn center have historically assisted with discharge planning and transitions of care for patients being sent home or to a facility. Despite these efforts, pharmacists were not formally involved in managing Burn Clinic patients. The objective of implementing a CDTM Protocol in Burn Clinic was to streamline management of burn-related pharmacologic issues.

Methods

The CDTM protocol allows the pharmacist to assess patients’ therapeutic needs related to thermal injury, inhalation injury, or dermatologic disorder. Disease states managed include: pain, agitation, delirium, insomnia, venous thromboembolism, skin and soft tissue infections, and complications of hypermetabolic burn response.

Results

In Burn Clinic, via in-person or telephone visits, pharmacists can independently evaluate and modify pharmacologic treatment regimens in accordance with state legislation, including initiation, renewal, and adjustment of drugs and vitamins. The pharmacist can also review, order, interpret, and conduct pertinent laboratory studies and wound culture results. In addition, the pharmacist completes medication reconciliation, performs patient education, and consults other healthcare providers, as needed. All visits, patient care, education, and treatment decisions are documented in the electronic record. “Incident-to” billing is completed at Level 99211, as this is a hospital-based clinic.

Conclusions

Historically, pharmacists were peripherally involved with Burn Clinic patients when issues arose, serving in an “as-needed” capacity. With more proactive involvement, pharmacists are uniquely positioned to help with de-prescribing, drug interactions, insurance issues, access to medications, adherence, and dose optimization. Implementing a CDTM protocol allows pharmacists to become more formally involved in post-discharge follow-up and to help manage ambulatory burn patients.
701 Outcomes of Patients with Burns Associated with Home Oxygen Therapy: A Systematic-Review and Meta-Analysis
Authors: Yoon Joshua S , Mafla Laura M , Ha Michael , Kim Justin , Keller Patrick R , Lagziel Tomer , Nam Arthur J , Galiatsatos Panagis , Hultman Charles S
Published: March 2022

Introduction

Home oxygen therapy (HOT) is frequently prescribed for patients with pulmonary dysfunction, which predisposes these patients to a unique health hazard at home. Given the combustibility of oxygen and method of delivery, HOT can result in burns that will affect primarily the facial area and may potentially be associated with inhalational injury. Additionally, a significant portion of patients on HOT are active smokers, which further heightens the risk of these HOT related burns. The outcomes of burn patients with burns associated with HOT is not yet completely understood. We conducted a systematic review and meta-analysis to characterize the outcomes of burn patients with burns associated with HOT.

Methods

We searched MEDLINE (Pubmed) for studies that reported on outcomes of burns associated with HOT. From this search, we screened 80 articles via online platform. Through our selection criteria, 17 articles focusing on patients with HOT-related burns were selected for systematic review and meta-analysis. Data was analyzed using a data analysis program.

Results

Seventeen studies observing a total of 1460 burn patients, published between 1990 and 2020, were included. Of these, one is a prospective study, twelve are retrospective chart reviews, and four were case reports/series. The mean age of the patients was 64.3 ± 4.5 years with a male to female predisposition of 1.5:1 and an average TBSA of 4.2 ± 4.1%. Of these burn patients, 93.4% were on HOT for COPD and 85.2% of injuries occurred while at home. Smoking caused 84.3% of all HOT-related burns and accrued a mean hospital charge of $73,628. With respects to clinical outcomes, the overall mortality rate was 11.3%, 33.6% required intubation, the average duration of intubation was 8.5 days, 31.3% had inhalational injury, 7.8% underwent tracheostomy, and 60.8% of patients were discharged home.

Conclusions

The majority of HOT-related burns are secondary to smoking and these injuries can result in significant morbidity and mortality and associated healthcare costs. A significant portion of these injuries can be prevented with smoking cessation and/or more judicious HOT allocation, however further studies and efforts will be needed to address this issue.
706 High Versus Low Dose Vitamin C in Burn Care
Authors: Jong Seungwon , Malkoc Aldin , Fine Kerry , Dao Tam , Wong David T
Published: March 2022

Introduction

While vitamin C is a regular part of burn management, there is no consensus on the most effective dose for a reduction in mortality, fluid resuscitation requirement, and other various clinical benefits. In this study, we aim to evaluate the potential protective effects of a higher dose of intravenous vitamin C in burn patients with greater than 40% total body surface area (TBSA) as compared to the effects on low dose oral vitamin C with lower TBSA burns.

Methods

A total of 54 subjects were retrospectively reviewed with burns greater than 20% TBSA from January 2018 to 2021. In our burn unit, patients with smaller burns were given 2,500 mg PO vitamin C and larger TBSA burns were given 15,000 mg IV vitamin C within 72 hours. During this period, we found 40 patients in the low dose group and 14 patients in the higher dose group. Demographics, length of stay, length on a ventilator, fluid requirements, number of procedures, days to the first infection, and mortality were compared using the Chi-square test.

Results

We found that there was a significant difference in the degree of burn on admission and reassessment between the dosing groups (30% vs. 48%, p = 0.006; 32% vs. 57%, p < 0.001). Overall fluid requirements for the first three days (9 liters vs. 25 liters, p < 0.001), length of stay (13 days vs. 38 days, p = 0.011), length on a ventilator (2 days vs. 13 days, p < 0.001), and total procedures required (1 vs. 5, p = 0.014) were also significantly higher in the group given the IV dose. No significant difference in other outcomes such as days until first infection and mortality rate were found, (p=0.451 and 0.326, respectively).

Conclusions

Parameters that were statistically significant were consistent with the higher burn TBSA. Despite the group with larger surface area burns to require much higher fluid requirements (25 liters vs. 9 liters in 72 hours), high dose IV vitamin C may have been protective since the outcomes of days until first infection and mortality rate had no significant difference compared to the group with the smaller TBSA burn which should have predictably better outcomes. This clinical study supports other studies that high dose vitamin C may improve outcomes from a reduction in capillary leak to mortality but an adequately powered randomized prospective approach is needed to better define the benefits as well as dosing.
709 Reconfiguration: Extracorporeal blood purification of a burn patient on ECMO
Authors: Basel Anthony P , Thomas Jason , Williams Alicia M , Stoffel Steven , Walter Robert , Mason Phillip , Britton Garrett W , Cancio Leopoldo C
Published: March 2022

Introduction

Patients who require extracorporeal membrane oxygenation (ECMO) have a very high mortality if they develop septic shock. Extracorporeal blood purification has been studied as an adjunct to antimicrobials but has yielded mixed or even disappointing results. The Seraph-100 Microbind Affinity Blood Filter (ExThera Medical Corporation, Martinez, CA) is currently undergoing clinical trials. The filter consists of polyethylene beads, coated in heparin sulfate, that irreversibly binds bacteria, fungi, viruses, and toxins. Seraph-100 therapy is traditionally delivered through conventional hemodialysis or continuous renal replacement therapy (CRRT), with the filter being placed in-line with these circuits. We present a case of a burn patient on veno-venous (VV) ECMO in septic shock, who was treated with a Seraph filter by connecting it directly to the ECMO circuit.

Methods

We present a case.

Results

A 34-year-old male presented with 56% thermal burns and grade 1 inhalation injury from a fuel tank explosion. He underwent a large-volume resuscitation for burn shock with lactated Ringer’s and albumin, receiving 18,152 mL (163 mL/kg) in the first 24 hours. He was placed on CRRT for acute kidney injury and underwent escharotomies of the hands and legs. On day 4, he developed bacteremia, septic shock and progressed to acute respiratory distress syndrome requiring VV ECMO. Extracorporeal blood purification was started via the Seraph-100 filter. Due to limitations of blood flow rates on CRRT, the Seraph-100 filter was added directly into the ECMO circuit. Inflow tubing was connected to an existing port on the oxygenator (Fig 1) and returned to the venous drainage by cutting a new port into the drainage tubing (Fig 2). The filter itself did not require any special configuration or orientation (Fig 3). This configuration allowed for pressures generated by the ECMO circuit to drive blood flow through the Seraph-100 filter (Fig 4). After 6 hours of treatment, vasopressor requirements drastically decreased.

Conclusions

Complications related to the Seraph-100 filter are rare but may include catheter thrombosis. This is typically due to the type of catheter used and/or the blood-flow rate through the filter rather than the filter itself. This issue was avoided with the ECMO configuration. Similarly, clinicians can avoid transient hypotension, blood loss from a clotted circuit, catheter-site bleeding, and other complications frequently associated with a renal replacement circuit.
720 Intensive Insulin Therapy in the Burn Intensive Care Unit: A Systematic Review of Literature
Authors: Peters Jasmine N , Collier Zachary J , Gillenwater Justin , Yenikomshian Haig A
Published: March 2022

Introduction

The significant burden of burn-related morbidity and mortality is partly due to the complex pathophysiological derangements that occur in the acute post-burn period. Critical care literature has pushed for tighter glycemic control, but these studies often use heterogenous groups of medical and surgical patients. Furthermore, some of these studies present conflicting evidence of whether there is true mortality benefit. Providers must balance the risks associated with hyperglycemia such as infection, inflammation, and pour wound healing against the risks associated with severe hypoglycemia, most notably coma and death. This study aims to review the literature on outcomes in tight glucose control regimens (glucose < 150mg/dL) in the burn ICU population to help guide further research and practice guidelines.

Methods

A systematic review of literature utilizing PubMed was conducted for any article published at any time. Searches used the AND function to identify articles with a burn term (burn injury OR burn care OR burn ICU OR burn OR thermal injury OR burned) and a glucose control related term (glucose control OR glycemic control OR glucose management OR insulin OR metformin OR glipizide). Inclusion criteria were English studies that describe intensive care unit (ICU) glucose management in adult burn patients. Exclusion criteria were involvement of children, animals, and settings outside of the ICU. Case reports, editorials, and position pieces were also excluded.

Results

The search identified 2,154 articles. Full text review of 61 articles identified 8 that met inclusion criteria. Two randomized control trials, 3 retrospective case-control studies, 2 retrospective cohort studies, and 1 systematic literature review. Only 1 study showed mortality benefit of tighter glucose control (< 150 mg/dL) compared to controls (< 200 mg/dL), while 3 studies showed no difference in mortality between cases and controls. Three studies demonstrated a reduction in infectious complications including sepsis, pneumonia, urinary tract infection, and bacteremia. Nearly all studies (6/8) showed increased rates of hypoglycemia with tight control, but very few instances of adverse sequela following hypoglycemia were noted.

Conclusions

Like the broader critical care population, tighter glucose control may be beneficial to burn patients but with some variability. Balancing the complications of hypoglycemia with hyperglycemia continues to be a challenge with no clear guidelines. Further research in a burn specific population would help create a safe and effective treatment algorithm which could be adapted widely.
726 Evaluating Outcomes and Pharmacoeconomics Associated with Collagenase Use in Burn Patients
Authors: Boyd Allison N , Walroth Todd A , Eberle Madilyn , Grooms Cortni , Hull Victoria , Hartman Brett C
Published: March 2022

Introduction

Collagenase is routinely used for partial thickness burns at our health-system. A 30 gram tube costs over $300, which creates financial challenges for uninsured patients and impacts revenue capture. The objective of this medication utilization evaluation was to characterize the use of collagenase and evaluate compliance to our institution’s criteria for use.

Methods

All admitted patients who received collagenase for burn injury from 3/14/21 to 6/14/21 were included. Patients were excluded if they were not admitted to the burn unit or left against medical advice. A cost analysis was also conducted.

Results

A total of 26 patients were included with a mean (SD) age of 45 (17) years. Most burns were thermal (77%) with a median (IQR) of 7.5% (1.9,13.5) total body surface area (TBSA). Twenty-three patients presented with mixed partial thickness or partial thickness burns (89%). The three remaining patients had full thickness burns, which is not an indication for collagenase use at our institution. There was a median of 1 (0,1) collagenase treatment day per TBSA. Median length of hospital stay was 5 (2,22) days with a length of stay per TBSA of 1 (1,2). Approximately 58% of patients required a surgical procedure. Of these, 8 had documented graft loss or failure while 7 did not. In those who experienced graft loss, median TBSA was higher [31.4 (7.8,57.5) vs. 10 (2.5,15); p = 0.269] and they required more surgeries [7 (1,9) vs. 1 (1,3); p = 0.104]. A potential total revenue of $428,280 was found. Additional cost data are provided in Table 1.

Conclusions

There was a high level of compliance with criteria for use, with some opportunities for improvement. Over 40% of patients who received collagenase for partial thickness burns were treated non-operatively, supporting its likely benefit, despite the cost. The potential exists for significant revenue for the health-system.
736 Intravenous Immunoglobulin in Stevens-Johnson Syndrome & Toxic Epidermal Necrolysis: Experience from a Tertiary Care Center
Authors: Hassan Manal , Ho Bao Vincent , Bhavsar Dhaval , Korentager Richard
Published: March 2022

Introduction

Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are rare severe cutaneous adverse reactions associated with high morbidity and mortality, however, there lacks an established treatment protocol. Treatment with intravenous immunoglobulin (IVIg) has demonstrated mixed success rates in improving mortality. It has been suggested that early intervention with IVIg in SJS/TEN patients may lead to a reduction in observed mortality rate when compared to the predicted rate. We present 24 patients with SJS/TEN treated in our burn unit with IVIg.

Methods

We conducted a retrospective analysis of patients who were hospitalized with the diagnosis of SJS/TEN in a specialized burn center over the years 2011-2020. Data regarding clinical factors, causative agent(s), disease severity, treatment received, and outcome were collected on chart review. SCORTEN and ABCD-10 prognostic scores were calculated for each patient at the time of admission. All patients were started on IVIg at the recommendation of dermatology. A standardized mortality ratio was obtained to compare the actual number of deaths to the predicted number based on SCORTEN and ABCD-10 formulas.

Results

A total of 24 patients were identified with a mean age of 49.8 ± 18.1 years. Most of the patients, i.e., 18 out of 24 had TEN, and 6 patients had SJS/TEN overlap with an overall average initial BSA involvement of 42.7% ± 25.3. Among the suspected drugs, sulfonamide antibiotics (41.7%) was the major predicted culprit. All patients were started on IVIg, 3 of which were treated in combination with corticosteroids. Most of our patients (23/24) received IVIg within 2 days of admission, but on average 11 ± 27 days (range: 2-135) after symptom onset. Many patients (10/24) experienced complications during hospital admission, such as: acute respiratory distress syndrome (8/24), sepsis (6/24), and anemia (2/24). There was no statistically significant difference in the overall observed mortality of 4 patients (16.7%) and the predicted overall mortality of 6.4 patients (26.7%) by the SCORTEN formula [standardized mortality ratio = 0.63; 95% confidence intervals, 0.17-1.61; P = 0.48], and the predicted overall mortality of 3.6 patients (15%) by the ABCD-10 formula [standardized mortality ratio = 1.12; 95% confidence intervals, 0.30-2.86; P = 0.96].

Conclusions

The findings of the present study do not support the clinical benefits of IVIg for SJS/TEN overlap and TEN patients.
750 Paddling into danger - Key lessons for a summertime
Authors: Schrire Timothy , Thakkar Mehul , Bednarz Bartlomiej
Published: March 2022

Introduction

Paddling pools are a source of entertainment for many children. In cooler climates, parents often attempt to heat up the water temperature by adding freshly boiled water into outdoor pools. Our Regional Burns Centre has seen many of these injuries and we wanted to investigate trends and prevalence.

Methods

Utilising the local Burn Injury Database, we searched for paddling pool related injuries which occurred between 2015-2020. We retrieved age, burn size and depth, need for surgical intervention and outcome, as well as circumstances surrounding the injury.

Results

We identified 26 injuries over six years, of which 11 were in 2020. The age of children ranged between 6 months and 13 years old (median 4 years 8 months). The majority, 22 (84%) of patients, had superficial partial thickness injuries. Only five patients (19%) had burns larger than 2% TBSA and only a single patient required general anaesthetic procedure to clean and dress the wounds. Two patients were admitted (length of stay 2- 5 days). Burns affected a range of locations with the majority being lower limbs (11) and upper limbs (8). Head and neck area was affected in 4 cases followed by flank (3), abdomen (2) and buttocks (2). Injuries occurred between April and August and the majority happened during the Friday – Sunday period 18 (69%). All burns occurred between 11:00 and 18:30, with average time being 14:40.

Conclusions

Paddling pools represent a common potential risk to children. With the recent of COVID-19 pandemic leading to closure of the schools, there has been a significant increase in paddling pool sales, resulting in an increase in these injuries and, without relevant education, they are expected to become more common.
754 The Effect of the COVID-19 Pandemic on Burn Care and Short-Term Patient Outcomes
Authors: Withers Jacquelyn , Gedallovich Jodi , Grossman Richard
Published: March 2022

Introduction

The COVID-19 pandemic has forced profound changes on many aspects of American healthcare delivery. Resource utilization and risk minimization have been the primary goals behind these shifts, and adaptations made to optimize public safety continue to affect patients. It is not known, however, how these changes have impacted burn patients. The aim of this study is to detect any effects the pandemic has had on this population by describing the incidence, nature, and short-term outcomes of patients treated by a single surgeon at a major burn center during the area’s shelter-in-place period.

Methods

A retrospective cohort study was performed using a database of one surgeon’s (RG) admissions and surgical procedures. All patients treated for acute burn injuries within the year following the announcement of COVID-associated shelter-in-place orders in the burn center’s area (March 2020-March 2021) were included. The control group consisted of the same surgeon’s patients treated in the prior year (March 2019-March 2020). All patients were included regardless of age. Patients treated for other conditions such as dermatologic issues or chronic burn sequelae were excluded. Delayed presentation was defined as an interval longer than 24 hours between injury and first medical encounter. Descriptive analyses were performed to compare the demographics, timing of presentation, treatment courses, and short-term outcomes between pre-pandemic and COVID period groups.

Results

408 patients were included overall, with 227 admitted pre-COVID and 181 during the pandemic. The only significant difference in demographics between groups was a higher incidence of homelessness in the COVID group (7 vs 13%, p < 0.04). Delayed presentation was not significantly different between groups (15 vs 17%, p=0.75). We found no significant differences between groups in rates of cellulitis or sepsis at presentation (9 vs 10%, p=0.8; 5 vs 8%, p=0.32) or during admission (16 vs 18%, p=0.54; 5 vs 8%, p=0.32). The mean number of surgeries per patient was 2 in both groups. Rates of autografting (62 vs 56%, p=0.24), lengths of stay (16 vs 17 days, p=0.34), readmissions (2 vs 4%, p=0.11), and deaths (2 vs 2%, p=0.74) were also similar. There were several complicated cases of delayed care in the COVID group after burns were evaluated initially via telemedicine, including one patient who presented in septic shock, though this finding did not reach statistical significance.

Conclusions

Our results demonstrate that the pandemic did not have a significant impact on many key aspects of acute burn care in this cohort. Patients in the pandemic period did not delay treatment at a higher rate, and short-term outcomes were comparable overall between groups. Further studies will be useful in understanding the effect of the pandemic and telemedicine on burn care in a broader context.
794 Use of Cultured Epithelial Autografts After Biodegradable Temporizing Matrix in Massive Burns
Authors: Heard Jason , Wallace David L , Sen Soman , Palmieri Tina L , Greenhalgh David G , Skipton Romanowski Kathleen S
Published: March 2022

Introduction

As burn care advances, patients are surviving with larger burn injuries, that previously would have been fatal. However, the need for autologous skin coverage continues to be an unmet need for massive burn injuries. Several attempts have been made to address this with various dermal substitutes, temporary coverage, and skin substitutes. For 25 years, Cultured Epithelial Autografts (CEA) have been used to treat large burn injuries, but this was met with variable success and has a mandatory pre-requisite lab time before it is ready for use. In 2018, Biodegradable Temporizing Matrix (BTM) that can be placed immediately on excised burns was first studied in burn patients, which has led to its increased use in subsequent years. This case series seeks to examine our experience using CEA following the application and ingrafting of BTM on large burns.

Methods

A retrospective review was conducted from 2017-2020 of adult burn patients admitted to an ABA verified burn center who underwent placement of both BTM and CEA. Demographics, mechanism of injury, burn characteristics, surgeries, and outcome data were collected. Surgical technique was early excision, BTM placement, a BTM integration period, repeat superficial excision, fibrin/thrombin spray, split thickness skin grafting with usually 6:1 mesh autograft, and finally CEA application. CEA was managed per manufacturer protocols. Descriptive statistics and univariate analyses were performed with Microsoft Excel.

Results

Eight patients met inclusion criteria. The average age was 29.3±5.3 years, 2nd degree TBSA 22.5±22.6%, 3rd degree TBSA 55.8±21%, and total TBSA was 78.3±4.4%. Four patients died during their hospital course and four survived to discharge. For survivors, the age length of stay was 135±23.6 days and they underwent an average of 8.5±1.5 total excision and/or grafting procedures. All patients had severe complications including severe sepsis/septic shock (n=8), gastrointestinal bleeds (n=2), acute respiratory distress syndrome (n=3), acute kidney injury or renal failure (n=4), pulmonary embolism (n=1) and myocardial infarction (n=1). The average time to 95% wound closure was 5 (79-147) days for survivors.

Conclusions

There continues to be an unmet need for autologous skin coverage in massive burn injuries when there is insufficient donor skin. In this series, we describe eight patients with massive burn injuries who underwent initial BTM placement, followed by 6:1 meshed autograft and CEA application. Although four patients died during their treatment course, the four surviving patients had acceptable wound closure rates and length of stay for their burn size.
801 Topical hemostatic agents in burn surgery: a systematic review
Authors: Battistini Andrea , Vrouwe Sebastian Q
Published: March 2022

Introduction

Acute burn surgery (tangential excision and grafting) has long been associated with significant intra-operative bleeding over large surface areas, where in adults approximately 200-250 mL of blood loss would be expected per %TBSA excised and grafted using traditional methods. Several techniques were introduced to limit bleeding, including tourniquets, tumescent infiltration, and topical agents. To date, no study has comprehensively investigated the available data regarding topical hemostatic agents in burn surgery.

Methods

A systematic review was performed by two independent reviewers using PubMed, Scopus, and Web of Science databases from first available to September 10, 2021. Articles were included if they were published in English and described or evaluated topical hemostatic agents used in acute burn surgery (excision and/or grafting). Animal studies and review articles were excluded. Data was extracted on the topical agent(s) used, their dosage, mode of delivery, hemostasis outcomes (if measured), and complications (if reported).

Results

The search identified 1982 non-duplicate citations, of which 134 underwent full text review, and 49 met inclusion criteria. Papers were grouped whether they compared (n=11, 22%), described (n=21, 43%) or secondarily described (n=17, 35%) topical hemostatic agents. Several authors (n=22, 45%) described topical hemostatics as part of a protocol that included other methods of blood conservation (tourniquet, tumescent infiltration, etc). In total, 31 studies incorporated a vasoconstrictor agent (epinephrine, phenylephrine, vasopressin), and 30 studies incorporated a procoagulant agent (thrombin, fibrin). Four studies incorporated other agents (hydrogen peroxide, tranexamic acid and collagen). The most common vasoconstrictor used was epinephrine, with doses ranging from 1:1,000 to 1:1,000,000. The most common procoagulant used was thrombin, with doses ranging from 10 to 1000 IU/mL. Among the comparative studies, outcomes of blood loss were not reported in a consistent manner, therefore meta-analysis could not be performed. The majority of studies (94%) were level of evidence III to V.

Conclusions

A multitude of topical hemostatic agents have been reported in the burn literature, with a wide range of dosages and modes of deliveries, as well as protocolization with other blood conservation techniques to limit blood loss during surgery. Determining the optimal topical hemostatic agent is limited by low quality data and challenges with consistent reporting of intra-operative blood loss and other clinically meaningful outcomes.
812 Evaluation of Dermal and Epidermal Replacement Strategies for the Treatment of Full-thickness Wounds
Authors: Hickerson William L , Mangum Lauren , Bell Cameron C , Bush Katie A
Published: March 2022

Introduction

In full-thickness (FT) wounds, autologous skin cell suspension (ASCS) is used in combination with widely meshed split-thickness skin grafts (mSTSGs) to obtain definitive closure, reducing donor skin requirements compared to traditional autografting (AG) techniques. In the treatment of these wounds, dermal matrices (DMs) are also often utilized to address various challenges including need for temporization, mitigation of contour defects, covering avascular structures, and modulation of scar formation. Varying DMs exist and are composed of different biologic and synthetic materials designed to address these clinical needs. The purpose of this study was to compare outcomes obtained in FT wounds using 3 different DMs coupled with ASCS+mSTSG in immediate or delayed AG procedures.

Methods

A FT excisional porcine wound model was used. DMs evaluated included a single-layer dermal matrix composed of bovine dermal collagen and elastin (Col/E), a bilayer construct composed of a bovine collagen-glycosaminoglycan with a silicone epidermal layer (Col/GAG), and a synthetic bilayer polyurethane DM (Poly/U).

DMs were applied, managed, and grafted following manufacturer’s recommendations. AG included ASCS+mSTSG (1:80 expansion, 3:1 mesh). Wounds were evaluated for inflammation, infection, DM take, AG take, re-epithelialization, and contracture over 49 days post-excision. Additionally, biopsies were evaluated to further inform tissue generation and healing outcomes.

Results

Results related to healing outcomes are reported in the table below. Inflammation at wound margins was noted during acute phase of healing for all DMs and visual cues for infection were noted in 1 wound for Col/E, 3 wounds for Col/GAG causing partial loss of DM, and 1 wound for Poly/U. All signs of infection were resolved by day 14.

Conclusions

ASCS+mSTSG can be used successfully over DMs composed of various materials in both immediate and delayed AG procedures. No difference was observed on percent AG take between the DMs, however the data suggest that time to definitive closure is impacted based on utilized DM and AG strategy, with potential implications on contracture.
Sit-ups and emergency abdominal surgery: a rare case of intestinal volvulus and resultant chylous ascites incited by abdominal exercises
Authors: Gritsiuta Andrei I , Bracken Alexander , Lara-Gutierrez Jorge , Gilleland William N
Published: March 2022

Chylous ascites is a unique phenomenon defined in the literature by ascitic fluid with a triglyceride content >200 mg/dl. This rather rare entity can be associated with a number of different pathologies related to abnormalities within the lymphatic system. This case report serves to demonstrate an intestinal volvulus and resultant chylous ascites found on exploratory laparotomy in an otherwise healthy individual who participated in routine, extreme abdominal exercises.
Omental lipoma: a rare cause of a giant intra-abdominal mass
Authors: Li Jia Xi Julian , Giddings Hugh Lewis , Owen Gareth
Published: March 2022

Primary tumors of the omentum, let alone omental lipomas, are rare causes of a large intra-abdominal mass. We report a case of an adult male presenting with an intra-abdominal mass, representative of a giant omental lipoma radiologically, confirmed on histopathology after complete resection at laparotomy. The case highlights the preoperative workup of a suspected omental lipoma, including the utility of various radiological modalities in differentiating from malignant pathologies, and anatomical characterization of the lesion for surgical planning.
The role of linearly polarized transverse MHD waves in heating the solar coronal plasma
Authors: Pandey V S , Kumar Ankit , Nayak M K
Published: March 2022

We derive a general dispersion relation for linearly polarized transverse magnetohydrodynamic (MHD) waves in an inhomogeneous, viscous, and resistive coronal plasma. We assume density structuring along the direction of polarization of the wave. In the linear regime and for an incompressible and homogeneous plasma, where the criterion of ignorable coordinates is satisfied, our solution corresponds to the customary Alfvén wave, which is basically dissipated by shear viscosity or resistivity. However, the assumption of density stratification along the direction of polarization of waves breaks down the criterion of ignorable coordinates, due to which transversal wave perturbations become compressible and, consequently, compressive viscosity turns out to be an important process. We find that for a typical coronal plasma with a magnetic field of 5 to 22 G, transverse body waves with a period of less than 10 s can dissipate energy on a time scale comparable to the coronal radiative time in their antisymmetric mode. Thus, it is possible that linearly polarized transverse wave perturbations dissipated by ion compressive viscosity maintain a hot coronal temperature.
Navigating Human Immunodeficiency Virus and Primary Care Concerns Specific to the Transgender and Gender-Nonbinary Population
Authors: Lieber Mark , Hamill Matthew M , Pham Paul , Pine Elyse , Crank Jill , Shah Maunank
Published: March 2022

Human immunodeficiency virus (HIV) prevention and treatment remain critically important to outpatient care among transgender and gender-nonbinary individuals. Epidemiologically, trans men and trans women are significantly more likely to have HIV compared with all adults of reproductive age. Here, we provide an overview of unique primary care considerations affecting transgender and gender-nonbinary individuals, including screening and treatment of HIV and other sexually transmitted infections as well as cancer screening and fertility preservation options. We also seek to review current literature and clinical practice guidelines related to drug–drug interactions between antiretroviral therapy (ART) and gender-affirming hormonal therapy (GAHT). In short, integrase strand transfer inhibitor–based therapy is not expected to have significant drug interactions with most GAHT and is preferred in most transgender individuals, including those on GAHT. Clinicians should also remain aware of current GAHT regimens and consider tailoring ART and GAHT to reduce cardiovascular and other risk factors.
Population Attributable Fractions of Underlying Medical Conditions for Coronavirus Disease 2019 (COVID-19) Diagnosis and COVID-19 Hospitalizations, Ventilations, and Deaths Among Adults in the United States
Authors: Nguyen Jennifer L , Alfred Tamuno , Reimbaeva Maya , Malhotra Deepa , Khan Farid , Swerdlow David , Angulo Frederick J
Published: March 2022

Background

Several underlying medical conditions have been reported to be associated with an increased risk of coronavirus disease 2019 (COVID-19) and related hospitalization and death. Population attributable fractions (PAFs) describing the proportion of disease burden attributable to underlying medical conditions for COVID-19 diagnosis and outcomes have not been reported.

Methods

A retrospective population-based cohort study was conducted using Optum’s de-identified Clinformatics Data Mart database. Individuals were followed up from 20 January 2020 to 31 December 2020 for diagnosis and clinical progression, including hospitalization, intensive care unit admission, intubation and mechanical ventilation or extracorporeal membrane oxygenation, and death. Adjusted rate ratios and PAFs of underlying medical conditions for COVID-19 diagnosis and disease progression outcomes were estimated by age (18–49, 50–64, 65–74, or ≥75 years), sex, and race/ethnicity.

Results

Of 10 679 566 cohort members, 391 964 (3.7%) were diagnosed with COVID-19, of whom 87 526 (22.3%) were hospitalized. Of those hospitalized, 26 640 (30.4%) died. Overall, cardiovascular disease and diabetes had the highest PAFs for COVID-19 diagnosis and outcomes of increasing severity across age groups (up to 0.49 and 0.35, respectively). Among adults ≥75 years of age, neurologic disease had the second-highest PAFs (0.05‒0.27) after cardiovascular disease (0.26‒0.44). PAFs were generally higher in Black persons than in other race/ethnicity groups for the same conditions, particularly in the 2 younger age groups.

Conclusions

A substantial fraction of the COVID-19 disease burden in the United States is attributable to cardiovascular disease and diabetes, highlighting the continued importance of COVID-19 prevention ( eg, vaccination, mask wearing, social distancing) and disease management of patients with certain underlying medical conditions.