bluuebunny/crossref_metadata_2025 huggingface dataset:
49 Post-Injury Trajectory of Body Mass Index Among Burn Survivors
Authors: Cato Liam , Shepler Lauren J , Kazis Lewis , Schneider Jeffrey , Suman-Vejas Oscar , Stewart Barclay , Kowalske Karen , Ryan Colleen
Published: May 2023

Introduction

Hypermetabolism following a burn injury causes perturbations of key cardiopulmonary and cellular functions which often persist long-term. Patients are advised to increase caloric intake to address this hypermetabolic state. However, potential weight change implications from such blunt strategies are not well studied. We aimed to 1) determine factors associated with weight change from discharge and 2) understand their relationship to other physical and psychosocial measures over time. By doing so, more tailored approaches to healthy weight management could be devised.

Methods

Adult participants that were enrolled in the Burn Model System (BMS) National Database after 2015 were included in the analysis. Weight was collected and BMI calculated during admission and at 0.5, 1, 2, and 5 year follow-ups. Mixed models included repeated measures controlling for correlated error of the outcomes and were used to assess the association of weight change with demographic, injury factors and psychosocial measures over time.

Results

A total of 698 individuals were included in the analysis. Median age was 48 years (IQR 33, 59), 218 participants were female (31.2%), median TBSA injured was 10% (IQR 3, 25), and 388 sustained flame injury (55.6%). Median BMI was 26.75 kg/m2 (IQR 23.67, 31.05). During follow-up, 446 participants (64%) had a median weight gain from admission to last follow-up of 2kg (IQR -2, 6.3). There were significant differences in weight trajectory between BMS centers (p=0.0003), which was included in subsequent models. Sex, marital status, and race were not associated with weight change. Increases in burn size (p< 0.0001) and number of months working after injury (p=0.03) were associated with greater weight, while older age at time of injury (p< 0.0001) was associated weight loss. Greater weight gain was associated with higher PROMIS-29 Physical Function (p=0.002) and Neuro-QOL (p=0.03) scores (meaning better) after one year. PROMIS-29 Sleep Disturbance score was associated with weight change only between years 2-5 of follow-up (p=0.029), with higher sleep disturbance score associated with lower BMI.

Conclusions

Most people living with burn injury experienced a modest weight gain after injury. Weight trajectory was impacted by several demographic factors including age, burn size, and amount time spent working, as well as physical and psychosocial measures (PROMIS-29 Physical Function, Neuro-QOL).

Applicability of Research to Practice

These factors can be used to inform anticipatory guidance, diet recommendations, and exercise programs for people with burn injury. The impact of tracking weight and health goals with patients in the outpatient settings should be more closely examined.
50 Metformin versus Insulin: Glucose Control and Safety in Burn Patients
Authors: Hallman Taylor , Wolf Steven , Golovko Georgiy , Song Juquan , El Ayadi Amina
Published: May 2023

Introduction

Patients suffering from moderate-to-severe burns are known to experience significant metabolic perturbations, such as hyperglycemia, as the result of a systemic hypermetabolic response. Hyperglycemia in these patients is in part due to the development of peripheral insulin resistance. Glycemic control is important, as hyperglycemia in patients with moderate-to-severe burns is associated with increased morbidity and mortality. Insulin and metformin are the first lines of treatment, with previous studies showing metformin to be superior to insulin in reducing burn-induced hyperglycemia. We queried a large multi-institutional national database to investigate whether the use of metformin in burn patients is associated with improved glycemic control and morbidity/mortality outcomes compared to insulin therapy.

Methods

We accessed TriNetX, a global health research network, and queried ICD-10 codes for burn injuries (T20-25, T30-32) across 54 participating health care organizations. We then identified cohorts of patients who were administered either metformin or insulin, but not both, within 1 week of burn. These cohorts were balanced using propensity score matching for age, gender, ethnicity, race, and type 2 diabetes mellitus and subsequently compared for the following outcomes: hyperglycemia (R73), hypoglycemia (E16.1, E16.2), lactic acidosis (E87.2), sepsis (A41), and death.

Results

A total of 16,569 patients were given insulin within 1 week of burn. This patient cohort had a mean age of 54 years, with 60% being male, 67% White, and 19% Black or African American. In contrast, 7,308 patients received metformin within 1 week of burn, with a mean age of 56 years, 55% female, 70% White, and 16% Black or African American. Burn patients who received insulin within 1 week of burn showed a comparative increased risk of 3.009% (p < 0.0001) for the development of hyperglycemia compared to those who were given metformin within 1 week of burn (RR: 3.165, 95% CI: 2.433-4.117). Additionally, burn patients given insulin displayed an increased risk of 2.452% for development of hypoglycemia (p < 0.0001, RR: 4.555, 95% CI: 3.317-6.255), 3.078% for development of lactic acidosis (p < 0.0001, RR: 17.541, 95% CI: 10.003-30.76), 3.67% for development of sepsis (p < 0.0001, RR: 12.106, 95% CI: 7.898-18.557), and 7.422% for death (p < 0.0001, RR: 13.996, 95% CI: 10.212-19.182).

Conclusions

Patients receiving insulin within 1 week of burn showed increased risk of poor glycemic control than those receiving metformin. Morbidity and mortality are also higher in those receiving insulin than those receiving metformin. Additional research is necessary to further understand these findings.

Applicability of Research to Practice

These findings should encourage clinicians to appreciate the importance of glycemic control in burn patients, as well as recognize the importance of choosing the most appropriate pharmacologic agent for glycemic control.
52 Open-Label, Expanded-Access Study of a Bioengineered Allogeneic Cellularized Construct in Adults With Deep Partial-Thickness Burns
Authors: Gibson Angela , Joe Victor , Carson Joshua , Litt Jeff , Carter Jeffrey , Holmes James
Published: May 2023

Introduction

An FDA-approved bioengineered allogeneic cellularized construct (BACC) provides burn surgeons with an alternative treatment for deep partial-thickness (DPT) burns and may reduce the need for autografting. A phase 3b, open-label, single-arm, multicenter, expanded-access study (NCT04123548) evaluated safety and clinical outcomes of BACC treatment in adults with DPT thermal burns containing intact dermal elements.

Methods

Patients aged ≥18 years with 3% to < 50% total body surface area of partial-thickness ± full-thickness thermal burns were enrolled. A single application of up to 1:1 meshed BACC was applied to ≤3 burn areas on the torso or extremities (≤2000 cm2 area of BACC). Patients were followed for 24 weeks. The primary endpoint was count and percentage of patients with treatment-emergent adverse events (TEAEs). Additional endpoints were patients and treatment sites with confirmed wound closure (complete re-epithelialization without drainage for 2 consecutive visits ≥2 weeks apart) of the BACC treatment site without autografting by Week 12; durable wound closure by Week 24; time to wound closure without autografting (determined by Kaplan-Meier estimate); scar evaluation using the Patient and Observer Scar Assessment Scale (POSAS); and patients with wound infection-related events. The sample was not designed or sized to determine efficacy.

Results

Overall, 52 patients were enrolled. Pruritus was the most frequently reported TEAE (n=22 [42.3%]). There were 2 (3.8%) BACC-related TEAEs; both were pruritus and mild in severity. There were 20 serious AEs in 10 (19.2%) patients; none were related to BACC. No patients discontinued the study due to TEAEs. There were 4 (7.7%) deaths (aspiration, myocardial infarction, self-injury, and Gram-negative rod sepsis); none were related to BACC. Wound infection-related events occurred in 5 (9.6%) patients. Overall, 46 (88.5%) patients and 87 (90.6%) BACC-treated wounds did not require autografting. Half of patients achieved wound closure by Week 5. At Weeks 12 and 24, observer and patient total POSAS scores (mean ± SD) were 18.7 ± 8.08 and 18.8 ± 9.84, and 24.5 ± 11.0 and 20.2 ± 12.5, respectively.

Wound closure of the BACC treatment site without autografting

Conclusions

There were no unexpected wound or BACC-related events. The safety of BACC supported its prescribing information. Patients treated with BACC achieved durable wound closure without autografting and thus showed expected clinical benefit in this population. The use of BACC in DPT burns in this study was donor-site sparing.

Applicability of Research to Practice

Treatment with BACC may offer a promising alternative to autografting for DPT burns.
61 Effect of Pre-Existing Hypertension on Cardiovascular Support and Mortality Among Major Burn Patients
Authors: Stephens Trina , Papp Anthony , Papp Bettina , Sheikh-Oleslami Sara , Griesdale Donald , Jain Fagun
Published: May 2023

Introduction

Hypertension (HTN) is the most common comorbidity seen in patients who sustain a major burn. HTN causes increased responsiveness of the autonomic nervous system to stressful stimuli, activation of RAAS, arterial and myocardial hypertrophy, and impaired vasodilation. Changes to these pathways are also seen in response to major burns. Given this common pathophysiology, patients with pre-existing HTN may demonstrate different mortality risk after major burn than those without HTN. The objective of this study is to compare the risk of in-hospital mortality among adult patients with and without pre-existing HTN admitted to the intensive care unit (ICU) with a major burn. In addition, we sought to determine the association of pre-existing HTN with the need for vasoactive agents, fluid resuscitation and urine output in the first 48-hours of ICU admission

Methods

Single-centre, historical cohort study using data from a Burn Registry, Intensive Care Database, and medical chart review. Variables of interest were demographic and injury characteristics, use of vasoactive agents, 12-, 24-, and 48-hour fluid requirements and urine output, and in-hospital mortality. We included adult (≥18 years) patients presenting with ≥20% total body surface area (TBSA) burns who were admitted to the ICU from January 2010 to August 2021. Pre-existing HTN was defined by pharmacy records showing the patient had filled a prescription for an anti-HTN medication within the 12-months prior to their burn. We compared variables of interest by HTN exposure and conducted univariate analysis to assess mortality risk

Results

199 patients met inclusion criteria. Of these, 145 records were complete. The mean (standard deviation, SD) age was 47 (7) years and TBSA was 37 (16) percent. Most patients were males (83.5%) who sustained a flame burn (87.6%) without an inhalation injury (28.5%). Pharmacy records revealed that 28 patients (19.3%) had pre-existing HTN. Mean (SD) 24-hour fluid requirements were 7.1 (5.6) L and 5.2 (3.2) L for HTN and non-HTN patients, respectively (p=0.17). Mean (SD) 24-hour urine output was 1024 (747) mL and 1314 (780) mL for HTN and non-HTN patients, respectively (p=0.12). Sixty-one percent of HTN patients required vasoactive agents in the first 24-hours compared to 46.2% of non-HTN patients (p=0.18). Pre-existing HTN was associated with a 5-fold increase in in-hospital mortality (OR 5.5, CI 2.2-14.0)

Conclusions

Preliminary results suggest differences in fluid requirements, urine output and mortality risk between HTN and non-HTN patients with major burns. An external registry has been queried to identify pharmacy records for the 54 patients with missing data

Applicability of Research to Practice

Identifying differences in mortality risk and need for cardiovascular support among burn patients with HTN changes our approach to counselling and caring for these patients
62 Effect of Glycemic Variability on Infectious Outcomes in Patients with Severe Burn Injuries
Authors: Hill David , Hoang Kristine , Ly Austin , Liu Xiangxia , Velamuri Sai
Published: May 2023

Introduction

Stress-induced hyperglycemia is a common manifestation of severe burn injury, due to increased catecholamines, glucagon, corticosteroids, and cytokines. The primary objective of this study was to evaluate the relationship between different measures of glycemic variability and infectious outcomes in burn patients.

Methods

This retrospective electronic chart review included patients admitted to a single American Burn Association-verified burn

center for the year of 2020. Infectious complication was defined as occurrence of proven infection, autograft loss, or

death. Glycemic variability indices tested include standard deviation, mean amplitude of glycemic excursions, J-index,

and coefficient of variability. Demographics were compared utilizing Fisher’s exact or Mann-Whitney U test, depending

on dichotomy. Logistic regression analysis was utilized to control for revised Baux score. Likelihood ratio test statistic was

utilized to compare strength of association.

Results

Three-hundred and ninety-two patients were admitted during 2020 and screened for inclusion. After applying exclusion

criteria, 112 patients remained in the study group. More than half were excluded for length of stay less than 3 days. Twenty-five

(22%) had at least one infectious complication (21 infections, 3 with graft loss, and 4 deaths). Revised Baux, age,

percent total body surface area burned, history of diabetes, and admission blood glucose were all higher in the group

with an infectious complication. Out of the indices tested, only mean glucose (Odds ratio, 95% confidence interval:

1.024, 1.004-1.045) and J-index (1.044, 1.002-1.087) were significantly associated with higher risk of an infectious

complication. Quantile analysis of mean glucose thresholds indicated > 150 mg/dL to have the strongest association with

infectious complications in burn patients.

Conclusions

Although J-index was significantly associated with infectious complications, mean glucose was also and has a simpler

derivation.

Applicability of Research to Practice

A liberal glucose control strategy should continue to be avoided in patients with burn injuries due to higher risk of infectious complication.
63 Adjunctive Ketamine Reduces the Risk of Developing Chronic Opioid Use in Burn Patients
Authors: Amador Dalton , Obias Isabel , Karam Kathleen , Soudah Chris , Arceneaux Amy , El Ayadi Amina , Song Juquan , Golovko Georgiy , Wolf Steven
Published: May 2023

Introduction

Opioid use for perioperative pain management in burn patients is associated with a high risk of developing chronic opioid use. Ketamine is commonly used as an analgesic adjunct due to its opioid-sparing effects. The purpose of this study is to determine whether analgesia with adjunctive ketamine reduces the risk of developing chronic opioid use in burn patients.

Methods

Burn patients who underwent burn-related surgeries were identified using relevant ICD-10 Codes. Data were collected using the TriNetX Research Network, a national research database providing de-identified patient medical records.

Burn patients undergoing surgical procedures were identified based on their use of opioids alone or in combination with ketamine as adjunctive analgesia. Both groups excluded patients with a prior history of opioid-related and psychiatric disorders to control for potential pre-existing conditions affecting the study outcomes. Outcome analysis included continued opioid use and related psychiatric disorders, including nicotine dependence and anxiety, up to one year after burn injury. Risk ratios for each outcome were then generated using a measure of association analysis through TriNetX.

Results

We identified 107,270 patients across 51 health care organizations who underwent burn-related surgeries within one month after burn injury. Excluded from the study were 3,296 (3.07%) patients who had a prior history of opioid-related and psychiatric disorders. The remaining 103,974 patients were sorted into respective groups that received opioids with ketamine (n = 8,328) and without ketamine (n = 51,413). The two cohorts were balanced using (1:1) propensity score matching for age, sex, race, ethnicity, and burn surface area.

Patients without ketamine had a higher risk of continuing opioid use (risk ratio [RR], 1.14, p < 0.001), developing nicotine dependence ([RR], 1.32, p < 0.001), and developing anxiety disorders ([RR], 1.21, p = 0.007) at least one year after burn injury.

Conclusions

Burn patients whose pain management included adjunctive ketamine ceased opioid use sooner and demonstrated a lesser risk of developing various psychiatric disorders associated with chronic opioid use.

Applicability of Research to Practice

This study supports the use of adjunctive ketamine as part of a multimodal approach to pain management in burn patients in order to minimize the risk of chronic opioid use.
66 Key Features of Virtual Reality Impact Effectiveness of Pain Reduction in Pediatric Burn Patients
Authors: Xiang Henry , Armstrong Megan , Thakkar Rajan , Fabia Renata , Noffsinger Dana , Ni Ai , Groner Jonathan
Published: May 2023

Introduction

Virtual reality (VR) is a safe and effective pain management during burn dressing. However, key features of VR that impact the effectiveness of pain reduction remains unknown.

Methods

Our randomized clinical trial included 90 children aged 6 to 17 years who were treated in the outpatient clinic of an American Burn Association–verified pediatric burn center. Active VR participants (n=31) played a VR game while passive VR participants (n=30) were immersed in the same VR environment without interactions. VR groups were also compared with a standard care group (n=29). The primary outcome was self-reported overall pain and worst pain during burn dressing using a visual analog scale (VAS; range, 0-100). Participants in the active and passive VR groups reported 3 key features of the VR game (engaging, fun, realistic) and all participants (VR and standard care group) reported how much time he/she thought about pain during the burn dressing. Key features of the VR game and time thinking about pain were reported using a scale ranging from 0 (not at all) to 100 (very much). A composite score was created by ranking scores of the 3 key features of the VR game and then summarizing them into one final composite score. Our study hypothesis was that the key features of the VR game significantly impact the effectiveness of VR in reducing pain during burn dressing care.

Results

Nonparametric Spearman correlation analysis indicated the active VR group reported statistically significant higher average scores for all 3 key features of VR (engaging: 78.9, 95% confidence interval (CI)=68.5-89.3; fun: 85.7, 95%CI=76.6-94.7; realistic: 73.1, 95% CI=62.3-83.8) in comparison with the passive VR group (engaging: 72.7, 95% CI=59.9-85.5; fun: 77.3, 95%CI=65.6-89.0; realistic: 59.1, 95% CI=44.7-73.5) (all p-value < 0.01). The composite VR score was also significantly correlated with how much time the participant thought about pain during the burn dressing (coefficient= -0.344, p=0.007). The final multivariate logistic regression model of reporting moderate-to-severe pain found that key features of the VR game were statistically significant factors for overall pain and worst pain after adjusting for age, race/ethnicity, healing degree, pain medication use within 6 hours, and anxiety score (p< 0.01).

Conclusions

This study provides evidence that key features of VR significantly impact its effectiveness in pain management among pediatric burn patients.

Applicability of Research to Practice

Active VR game is more effective and should be used for pediatric pain management.
72 Multi-Spectral SWIR Imaging in Humans Reveals Correlations with Distinct Skin Burn Depths
Authors: Nunez Johanna , Levi Benjamin , Hong Jonathan , Carlson Deborah , Huebinger Ryan , Chan Rodney , Wan Bingchun , Mironov Sergey , Mandell Samuel , Goverman Jeremy , Akarichi Chiaka , Berenfeld Omer , Arnoldo Brett , Clark Audra
Published: May 2023

Introduction

Burn depth determination is a critical aspect of burn patient care but currently lacks accuracy in clinical practice. We have shown first in animal models and then in a two-patient characterization that Short Wave Infrared (SWIR) imaging, which penetrates tissue better than visual or near-infrared light and is very sensitive to water content, can distinguish between superficial and deep tissue necrosis. Here we present the findings from our pilot study of 10 patients showing the use of multi-spectral SWIR imaging of human burn injury as a potential technique for burn depth determination.

Methods

Ten patients admitted for mixed depth thermal injuries between 5-40% TBSA were analyzed using our SWIR assessment tool. Prior to burn excision the SWIR system was used to image burn areas and normal skin at 4 different SWIR wavelengths (Figure 1A). Standard photographs from imaged areas were collected and presented for 5 independent, blinded, surgeons’ assessments. Using the visual and SWIR images, 5-15 regions of interest (ROI) were selected from each of the burned areas and normalized to adjacent normal skin and the reflected light intensity in each ROI was averaged at each wavelength. Statistics were done using Mann-Whitney U tests.

Results

Visual and SWIR images were collected from burn areas in 10 patients for a total of 273 burn ROIs. The ROIs were assessed by the surgeons with ROIs being agreed upon as being superficial or superficial partial thickness (SPT) (n=47), deep partial thickness (DPT) (n=97), or full thickness (FT) (n=129) burns by a majority (60% or above) consensus. As seen in Figure 1B, the reflectance intensities (RIs) from superficial and SPT burns were significantly different than the DPT burns at the 1940 nm wavelength (p=0.05) and significantly different than FT burns at 1200 nm (p=0.008) and 1940 nm (p=0.009). When DPT and FT burns were compared there was a significant difference a 1200 nm (p=0.003) and 2250 nm (p=0.01).

Conclusions

Here we present a 10 patient SWIR pilot study demonstrating distinct ROIs of SWIR wavelengths for different burn depths based on consensus surgeon assessments. Overall, as burn depth increases, the 1200 and 2250 nm wavelengths show increasing RIs and 1940 nm show decreasing RIs. These results motivate further studies of SWIR imaging including pending histological analysis in the hope to non-invasively and accurately identify operative versus non-operative burns.

Applicability of Research to Practice

This new SWIR technology may enable us to more objectively assess burn depth, leading to improved surgical decision making and better patient outcomes.
81 Post-Burn Psychosocial Outcomes in Pediatric Minority Patients: A Burn Database Cross-sectional Study
Authors: Won Paul , Ding Li , McMullen Kara , Yenikomshian Haig
Published: May 2023

Introduction

Racial and ethnic minority burn patients often face barriers to longitudinal psychosocial support after injury. Studies utilizing the Burn Model System (BMS) National Database show adult minority patients report worse psychosocial outcomes during burn recovery in domains such as body image or social re-integration. No study to date has investigated differences in psychosocial outcomes by racial or ethnic category in the pediatric population using the BMS database. This study examines eight outcomes in minority pediatric patients to better characterize potential differences in the pediatric patient population.

Methods

Patients under 18 years old treated for burn injury between 2009 and 2019 consented to participate in a multi-center longitudinal study were included in the current sample. We analyzed eight outcomes using the National Institute of Health Toolbox and PROMIS-25 measures with higher reported scores indicating worse symptom severity. Multi-level, linear mixed effects, regression modeling analyzed associations between race/ethnicity and outcomes at three time points (discharge after index hospitalization, 6- and 12- month post-injury.

Results

The total cohort of 277 patients were 81% male (n = 182) and on average 8.78 years old (range: 3-18 years at time of injury). When surveyed 12 months after injury, pediatric Hispanic patients reported a mean fatigue score of 45.8 (95% confidence interval (CI): 41.6, 49.9) compared to pediatric non-Hispanic patient score of 43.0 (95% CI: 37.1, 48.9). At 12 months, Hispanic patients reported a mean anxiety score of 46.1 (95% CI: 42.7, 49.5), compared to 41.4 (95% CI: 25.8, 47.1) reported by non-Hispanic patients. At 12 months after injury, Hispanic patients reported a mean peer relationship score of 51.1 (95% CI: 47.2, 55.1) compared to non-Hispanic patients' score of 55.5 (95% CI: 50.3, 60.6). Hispanic patients also reported a mean pain interference score of 44.7 (95% CI: 42.3, 47.0) compared to non-Hispanic patients' score of 38.3 (95% CI: 34.9, 41.6) at 12 months after injury.

Conclusions

Following burn injury, pediatric Hispanic patients report worse outcomes in several psychosocial domains compared to pediatric non-Hispanic patients, although differences were not statistically significant. However, as significant differences in outcomes exist in adult Hispanic/Latino patients, this study supports the need for further evaluation into potential factors that lead to worse outcomes in Hispanic populations.

Applicability of Research to Practice

Although pediatric Hispanic patients do not report significantly worse outcomes than non-Hispanic patients in short term burn recovery, these patients may benefit from further counseling and psychosocial support after injury.
82 Comparison of Parent vs. Burn-Injured Youth Scores on the Strengths and Difficulties Questionnaire
Authors: Rimmer Ruth , Bay Curt , Kalil Emile , Chacon Daniel , Mendoza Erika , Foster Kevin
Published: May 2023

Introduction

Research regarding the prevalence of psychopathology issues in burn-injured youth is limited. The Strength and Difficulties Questionnaire (SDQ) is valid for both self- and parent-report, and is widely used. This study sought to evaluate the level of agreement between the youth self-report and parental response.

Methods

Respondents included 36 adolescent/parent dyads. The youth included 11-18 years old, 14% African American, 19% Hispanic and 44% White, 19 females, 17 males with 58% reporting both visible & hidden scars. The SDQ is a widely used behavioral screening tool assessing children’s positive & negative attributes on 5 scales: 1) Emotional Symptoms, 2) Conduct Problems, 3) Hyperactivity/Inattention, 4) Peer Problems, 5) Prosocial Behavior as well as a Total Difficulties Score.

Results

Youth reported significantly higher scores than parents on Total Difficulty (P < 0.001). They had significantly higher scores on all scale scores – Emotional Problems (P = 0.01), Hyperactivity (P = 0.001), Conduct Problems (P = 0.041), Peer Problems (P=0.041), Internalizing (P = 0.005), and Externalizing Behaviors ((P < 0.001), but not the Pro-Social Scale (P=0.303). Correlations between self- and parent-report were significant only for the Hyperactivity scale, r=.40, p=0.017.

Conclusions

The large difference in youth vs. parent responses is of concern because study parents appear to be unaware of psychosocial issues challenging their children. This study mirrors other research which has documented a lack of awareness of parents regarding children’s reported anxiety disorder symptomology.

Applicability of Research to Practice

Healthcare providers & parents should discuss burn-injured youths’ feelings regarding their progress. Providers should not rely solely on parents when determining the well-being of pediatric survivors. This survey can be completed easily by youth and parents in the aftercare setting and used as a tool for recommending intervention when difficulties are present.
83 Screen & Intervene : Mental Health Screening in the Burn Clinic
Authors: Colarusso Linda , Strait Eli , Lee Jeanne , Smith Alan
Published: May 2023

Introduction

Studies have demonstrated an increased prevalence of depression and PTSD in individuals with burn injuries during the first year of recovery. Mental health screening of patients at all burn centers is recommended. With the addition of an outpatient social worker, our burn center identified a need to standardize the burn clinic’s mental health screening process to address the mental health needs of patients. This performance improvement project sought to improve mental health screening in the burn clinic and subsequent referrals to community resources.

Methods

From March to August of 2022, the PHQ-2 and PC-PTSD were administered to 99 clinic patients during one of the patient’s initial visits. Patients completed the screening independently using a paper form. For pediatric patients < 12 years old, the primary caregiver filled out the form. Of the 99 patients who completed the screening, 51 were previously admitted to our inpatient burn center and 48 were treated only as outpatients (F=36, M=63). The age range of patients was 10 months to 88 years old. TBSA % burned ranged from .15% to 70%. A score of 2 or more on either of the screening tools resulted in further assessment by the social worker to determine appropriate next steps. The chi-square test was used to analyze the data collected.

Results

A total of 36/99 patients screened positive for depressive symptoms, 33/99 screened positive for Acute Stress Disorder (ASD)/Post Traumatic Stress Disorder (PTSD) symptoms, and 23/99 screened positive for both depressive and ASD/PTSD symptoms. All patients with a positive screen on either tool were provided with education regarding mental health resources and offered a referral for services. Of the 99 patients screened, 26 accepted a referral to the local burn foundation and/or an alternate mental health provider for support services. The other 73/99 declined a referral for follow up. There were statistically significant correlations between positive ASD/PTSD screenings and inpatient hospitalization (22/99 p=0.033), PTSD and median TBSA (p= 0.011), and PTSD and age (45-64yo, p=0.028). Females (19/36, p=0.01) were more likely than males to report symptoms of depression and both PTSD & depression (p=0.001), while females (12/36) and males (21/63) were equally likely to report symptoms of PTSD.

Conclusions

Mental health screening of individuals in our burn clinic yielded a significant number of positive screens for depression and ASD/PTSD symptoms, validating the need for a standardized screening process. Positive screens resulted in increased referrals to community and mental health resources.

Applicability of Research to Practice

Performing mental health screenings in the outpatient arena is vital to address the mental health needs of individuals with burn injuries.
88 Does Weight Matter? A Secondary Analysis from ABRUPT
Authors: Fine Jeffrey , Taylor Sandra , Greenhalgh David , Cartotto Robert
Published: May 2023

Introduction

Burn shock resuscitation fluids should be titrated to achieve a urine output (UOP) of 0.5 to 1 mL/kg/hr. It is unknown whether this UOP goal should be indexed to actual body weight (ABW) or predicted body weight (PBW). The purpose of this study was to evaluate differences related to ABW and PBW-indexed UOP using data from ABRUPT.

Methods

We queried the database from ABRUPT, which was a multicenter prospective observational study of acute fluid resuscitation practices involving 379 adults treated at 21 burn centers between 4/2017 and 6/2020. Values are presented as the mean ± SD or median (IQR) as appropriate.

Results

There were 379 subjects (age 46 ± 15.9 yrs, %TBSA burn 31.6 (18), 12.7% with inhalation injury). ABW (N=379) was 90 ± 24.8 kg and PBW (N=375) was 69.5 ± 10.4 kg. ABW exceeded PBW in 84% of subjects. In the 1st 24 h post burn, UOP was 0.87 (0.51) mL/kg ABW/h compared to 1.1 (0.6) mL/kg PBW/h (Figure). Total UOP in the 1st 24 h did not differ between body mass index (BMI) categories. Neither ABW UOP nor PBW UOP was predictive of the decision to initiate 5% albumin (OR and 95% CIs 0.914 [0.754, 1.109] and 0.882 [0.687, 1.133], respectively). We compared subjects with a mean hourly UOP < 0.5 mL/kg/h based on ABW but still > 0.5 mL/kg/h based on PBW (N=61) with subjects whose mean hourly UOP remained > 0.5 mL/kg/h based on ABW (N=283). Subjects whose UOP was < 0.5 mL/kg ABW/h but > 0.5 mL/kg PBW/h were significantly older than subjects whose UOP was > 0.5 mL/kg ABW/h (51.2 [15.6] Vs 44.4 [15.4] yrs, p=0.002), but otherwise we found no significant differences within the 1st 24 hours between these two groups in heart rate, blood pressure, peak lactate, creatinine, total fluids administered, or SOFA score. There were no significant differences in SOFA at 48 and 96 hours, ventilation days, need for dialysis in the 1st 96 hours, or survival.

Conclusions

ABW in a large majority of the ABRUPT population was greater than PBW. Consequently UOP was numerically lower when indexed to ABW than when indexed to PBW. Patients whose UOP was < 0.5 mL/kg ABW /h but > 0.5 mL/kg PBW/h did not appear to have any worse outcomes than those whose UOP remained > 0.5 mL/kg ABW/h.

Applicability of Research to Practice

This study generates a hypothesis and a question as to whether titration based on PBW UOP rather than ABW might result in more aggressive titration and administration of less resuscitation fluid, since PBW-indexed UOP ‘looks’ higher. While this can only be answered in a randomized comparison between the two approaches, our study did not identify any adverse outcomes in patients who had a UOP < 0.5 mL/kg ABW/h but > 0.5 mL/kg PBW/h, which might indicate that titration to > 0.5 mL/kg PBW is feasible.
90 Higher Initial Formula for Resuscitation After Severe Burn Injury Means Higher 24-Hour Volumes
Authors: Rizzo Julie , Coates Elsa , Serio-Melvin Maria , Aden James , Stallings Jonathan , Foster Kevin , AbdelFattah Kareem , Pham Tam , Salinas Jose
Published: May 2023

Introduction

Initial fluid infusion rates for resuscitation of burn injuries typically use formulas based on patient weight and total body surface area (TBSA) burned. However, the impact of this rate on overall resuscitation volumes and outcomes have not been extensively studied. The purpose of this study was to determine the impact of initial fluid rates on 24 hour volumes and outcomes using the Burn Navigator (BN).

Methods

The BN database is composed of 300 patients with > 20% TBSA, >40kg that were resuscitated utilizing the BN. Four study arms were analyzed based on the initial formula – 2ml/kg/TBSA, 3 ml/kg/TBSA, 4 ml/kg/TBSA or the Rule of Ten. Total fluids infused at 24 hours after admission were compared as well as resuscitation-related outcomes.

Results

A total of 296 patients were eligible for analysis. Higher starting rates (4 ml/kg/TBSA) resulted in significantly higher volumes at 24 hours (5.2 + 2.2 ml/kg/TBSA) than lower rates (2 ml/kg/TBSA resulted in 3.9 + 1.4 ml/kg/TBSA). No shock was observed in the high resuscitation cohort, whereas the lowest starting rate exhibited a 12% incidence, lower than both the Rule of Ten and 3 ml/kg/TBSA arms. There was no difference in 7-day mortality across groups.

Conclusions

Higher initial fluid rates resulted in higher 24-hour fluid volumes. The choice of 2ml/kg/TBSA as initial rate did not result in increased mortality or more complications. An initial rate of 2ml/kg/TBSA is a safe strategy.

Applicability of Research to Practice

Utilizing a lower starting fluid rate is a safe strategy and should considered after severe burn injury.
91 Precursors to Oliguria During Acute Burn Resuscitation: A Secondary Analysis of a Prospective Observational Study
Authors: McHargue Cody , Rizzo Julie , Aden James , Pham Tam
Published: May 2023

Introduction

Though commonly used to tailor fluid resuscitation, urine output may be a late indicator of impending burn shock. We sought to identify precedents of an early oliguric episode within 6 hours of admission. We hypothesize that specific variables may indicate early at-risk features during resuscitation.

Methods

We performed a secondary analysis of adults enrolled in the Burn Navigator resuscitation trial. We divided into two cohorts: those with oliguria (< 30ml/hr) and those without. Variables were compared by descriptive statistics.

Results

A total of 146 adults met inclusion criteria. More oliguric patients experienced systolic pressures < 90 mmHg (p=0.02) or Diastolic pressures < 40 mmHg (P=0.01). The minimum bicarbonate level (p=0.04), larger TBSA (p=0.01) and larger full thickness component (p=0.004) were all predictors of early oliguria. There were also more female patients (p=0.003) in the oliguric group. No cohort difference was observed for these variables: burn mechanism, percent partial thickness, HR >140 beats per minute (BPM) or hourly change in HR >10 BPM, temperature < 36C, hourly MAP drop >10 mmHg, creatine kinase, age, body mass index, hematocrit level, alcohol level, or methamphetamine use.

Conclusions

Specific variables and physiological derangement thresholds precedes the first oliguric episode during major burn resuscitation. These variables constitute at-risk features that may help derive future algorithms for efficient burn resuscitation.

Applicability of Research to Practice

Precursor variables of an early oligouric episode identify patients needing closer fluid titration.
94 A Review of the Utility of the Readmission Risk Scale in Hospitalized Burn Injured Patients
Authors: Patel Jay , Richey Karen , Islas Claudia , Foster Kevin , Bay Curt , Kesler Natalie
Published: May 2023

Introduction

The burden of wound care post-hospitalization is often overwhelming, not only for patients and their families but also for home health nurses and intermediate care facilities. Inadequate wound care following hospital discharge can lead to wound deterioration and hospital readmission. These readmissions impact the patient, as well as healthcare institutions, physicians, payor sources, and policy makers. Readmission Risk Scales (RSS) exist but typically focus on those patients with chronic illness. Our hospital’s RRS consists of 16 items: patient without a primary care physician (PCP), active problem list > 2, past medical history > 2, age ≥ 50, lives alone, high fall risk, length of stay > 10 days, mental health disorder, diabetes, heart failure, COPD, alcohol abuse, drug use, uninsured/Medicaid, > 2 ED visits in previous 6 months and prior readmission within 30 days. The purpose of this study was to evaluate the fit of our current RSS for burn patients and identify other variables that may be predictive of readmission in burn patients.

Methods

This was a retrospective chart review of burn patients admitted over a 1-year period. Primary outcome measures were RSS scores, individual RSS variables, social determinants of health and incidence of readmission within 30 days of discharge. Readmitted patients were compared to those who did not require readmission. Descriptive statistics were calculated, and bivariate and multivariable logistic regressions (forward LR) were used to identify variables that contributed uniquely to readmission.

Results

A total of 600 burn patients were admitted over the study period of which 449 met inclusion/exclusion criteria. Thirty-two (7%) of these patients were readmitted within 30 days of their initial hospital discharge. In bivariate analyses, only 4 of the current RRS variables were statistically significant predictors of readmission within 30 days, patient without a PCP (p=.019), active problem list > 2 (p< .001), mental health disorder (p=.004) and drug use (p< .00004). However, when these variables were tested simultaneously in one predictive equation, only drug use remained significantly predictive. The total RSS score accounted for only 1.1% of the variance in readmission within 30 days.

Conclusions

The national readmission rate is 12%, and our overall rate was substantially below this. However, our current Readmission Risk Scale is not predictive in identifying those patients at risk for being readmitted within 30 days of discharge. Further investigation is warranted to identify additional variables to identify at risk patients.

Applicability of Research to Practice

A valid readmission risk assessment tool, would be beneficial to identify patients who are at risk for readmission and enhancing discharge planning.
95 Shifting Payor Mix May Challenge Financial Sustainability of Burn Centers
Authors: Oh Jamie , Sheckter Clifford , Stewart Barclay , Wang Virginia
Published: May 2023

Introduction

The financial sustainability of regional burn centers is essential to the health of the populations they serve, and to the broader development of burn prevention and care innovations. Additionally, per capita out-of-pocket personal health expenditures (OOP) have risen steadily over the last decade. Lower pre-injury income has been shown to predict poorer post-injury quality of life and higher risk of financial toxicity. Given these multi-level dynamics, we aimed to characterize the changing payor landscape and OOP from 2010-2020 at an American Burn Association-verified center to delineate the financial implications of these changes on the health system and per-patient financial liability.

Methods

We merged burn registry and financial data from 2010 to 2020. Financial variables included payor status, pay-to-charge ratio (% of insurance reimbursement/total hospital charges), financial liability (remainder of charges after insurance reimbursement), and patient payment (dollars). Analyses of trend were performed using Pearson’s chi-squared analysis for counts and ANOVA for means.

Results

The percentage of self-pay patients decreased from 2010 to 2020 from over 13% to under 4% of the total number of patients annually (p< 0.001), corresponding with an increase in the percentage of Medicaid patients from 30% to over 40% of the total number of patients annually (p< 0.001). This change became significantly more pronounced in 2014. Notably, most major provisions of the Affordable Care Act were phased in by January 2014, including state-level Medicaid eligibility expansion. Medicaid consistently displayed a lower pay-to-charge ratio (30-40%) than both commercial insurance (~70%) and Medicare (50-80%) across the decade (p< 0.001). Total financial liability increased across the decade for commercial insurance (p< 0.001), Medicaid (p=0.013), and Medicare (p=0.015). From a patient perspective, the average payment burden did not change significantly across the decade despite rising healthcare costs. The average per-patient owed amount ranged from $0-$1000 for self-pay, $150-$200 for Medicare patients, and $500-$600 for patients with commercial insurance.

Conclusions

Burn centers must remain financially sustainable to continue serving their communities. The shifting landscape of healthcare with a population increasingly reliant on Medicaid impacts a hospital’s financial sustainability. This change demonstrates that minor differences in OOP for the average patient may have large implications for hospital systems given the low pay-to-charge ratio of Medicaid.

Applicability of Research to Practice

This work highlights the changing payor landscape and the impact it may have on burn center financial sustainability and risk of patient financial toxicity, particularly among already vulnerable Medicaid recipients.
106 Adipose Derived Stem Cell Paracrine Factor Release in Smokers vs Non Smokers with Burn Injuries
Authors: Deville Paige , Smith Alison , Phelan Herbert , Carter Jeffrey , Warren Olivia , Fontenot Cameron
Published: May 2023

Introduction

Adipose-derived stem cells (ADSCs) have an important role in the modulation of burned tissue repair through the release of paracrine factors that stimulate the wound healing response. In this study, we tested the hypothesis that smoking status alters the profile of paracrine factors secreted from ADSCs isolated from damaged adipose tissue.

Methods

Adipose tissue was collected from adult patients (N=8) with severe burn injuries ( >20% total body surface area) at the index operation. ADSCs were extracted and cultured in vitro. Supernatants were harvested 30 hours after plating and used for cytokine determinations by Multiplex assay. Fluorescence activated single cell sorting (FACS) confirmed their phenotype with markers CD 90, CD 166, and CD 73. Univariate analyses were performed to compare the two cohorts (Smokers vs non smokers). All outliers were removed.

Results

Higher amounts of anti-inflammatory cytokines IL-4(p=0.03) and IL-10(p=0.04) and pro-inflammatory cytokines TNF-alpha (0.03), IL-8, and IFN-gamma (p=0.03) were detected in burn patients who were current everyday smokers when compared to nonsmokers, or former smokers. No significant differences in supernatant concentrations of IL-17, IL-1 beta, TGF-alpha, IL-6, and IL-13 were observed (p >0.05). Mortality was higher in the smoker group when compared to non-smokers (p=0.02).

Conclusions

The results from this study suggest that smoking status in patients with a major burn injury may alter the profile of paracrine factors secreted from ADSCs, and on-going studies will increase sample size and refine experimental approach. Furthermore, these results support the need for studies examining the systemic effects of smoking status of patients suffering burn injuries impacts the wound healing.

Applicability of Research to Practice

Study the effects of smoking on wound healing in burn injuries.
110 Sleep After Discharge: A Cohort Study of Burn Participants in a Home-Based Virtual Rehabilitation Trial
Authors: Rhodes Lori , Sibbett Stephen , Orton Caitlin , Carrougher Gretchen , Stewart Barclay , Bunnell Aaron , Pham Tam
Published: May 2023

Introduction

Patients with major burns experience physiologic changes that can impact their recovery for months after hospital discharge. Little is known about sleep quantity and quality in the post-discharge period. Here, we report on actigraphy sleep data for participants enrolled in a prospective trial of home-based virtual rehabilitation.

Methods

We conducted a randomized controlled trial to evaluate the effect of home-based rehabilitation using Jintronix® modules and Kinect® motion sensor on adherence to therapy. In both intervention and control (usual care) groups, participants were provided a wrist actigraphy accelerometer device (Vivofit®) to wear for the 12-weeks intervention. Sleep data were retrieved remotely and analyzed. Actigraphy data were defined as complete and analyzable if participants had 5 out of 7 days of actigraphy wear and upload in a week. Average weekly sleep was calculated and reported by group assignment. Descriptive statistics were used for comparisons, with p< 0.05 deemed as significant.

Results

Forty-four participants were enrolled with a 1:1 group assignment. Mean age was 38.5 years (SD=14.8), mean TBSA was 15.6% and most were male (68%). Average sleep was well within healthy population norms, with little difference between intervention and controls (7.29 vs.7.20 hours respectively, p=0.25) in the 90 days after discharge. Participants in control group spent more time in light sleep (4.05 vs. 3.88 hours, p< 0.01). The percent deep sleep, however, was comparable to healthy population norms (2.92 and 2.75 respectively, p=0.25). Participants in the control group experienced a higher proportion of nights with sleep disturbances (0.75 vs. 0.70, p=0.006).

Conclusions

Remote wrist wearable-wearable actigraphy data provide an important glimpse into sleep duration and quality for burn injured individuals in the 12 weeks after hospital discharge. An encouraging finding was that total sleep and deep sleep proportion for this cohort were comparable to healthy population norms. Though intervention and control groups were similar in total sleep hours, there were important differences in sleep quality.

Applicability of Research to Practice

Remote data acquisition on post-discharge sleep is feasible.