bluuebunny/crossref_metadata_2025 huggingface dataset:
717 Management of Gynecologic Involvement in Stevens-Johnson Syndrome (SJS)/ Toxic Epidermal Necrolysis Syndrome (TENS)
Authors: Knapp Rachel , Ciccone Marcia , Yenikomshian Haig , Gillenwater Justin
Published: May 2023

Introduction

Stevens-Johnson Syndrome (SJS)/ Toxic Epidermal Necrolysis Syndrome (TENS) are rare and potentially life-threatening dermatologic conditions that require interdisciplinary management (Shanbhag et al., 2020). One of the most painful and traumatic is vaginal mucosal involvement. Gynecologic complications have been historically undermanaged, and lack of acute intervention can lead to dyspareunia, adhesion formation, and increased risk for vaginal cancers (Kaser et al., 2011). Unfortunately, treatment is variable but typically involves use of vaginal dilators, which can be painful, and often traumatic for both patient and provider. The purpose of this study was to analyze the utilization of these treatments and to observe any sequelae from gynecological involvement.

Methods

Retrospective chart review was completed for all female patients with a diagnosis of SJS/TENS who were admitted to a single center burn unit from 2015-2022. Trends in age, gynecologic involvement, wound care strategies, and outcomes were assessed.

Results

Twenty-nine patients met inclusion criteria. These patients ranged from 9-82 years of age with a mean of 43 (STD 21). Ten percent died in the hospital, 14% were transferred to another hospital, and the remaining patients were discharged to home or a rehabilitation facility. Of these 29 SJS/TENS patients, 59% had gynecologic involvement of which 52% received gynecologic interventions. Gynecologic interventions included use of vaginal dilators (67%), topical steroids (60%), antifungal ointment (33%), and menstrual suppression (13%). For pediatric populations, patient discomfort and family concerns limited pelvic exam and vaginal interventions. Accommodations for pediatric patients included completion of examination and treatment under anesthesia and education of parents about the treatment process. While 2 patients were confirmed to have no vaginal adhesions in follow up appointments, documentation of future vaginal complaints was not available for most patients.

Conclusions

Gynecologic management is an important part of SJS/TENS treatment with wide variability in practice patterns not only nationally but at a single setting institution. Outcomes from treatment versus non treatment with steroids +/- dilation is equivocal. Providers must be better at screening for symptoms in outpatient follow up. When forming new algorithms, special consideration among pediatric populations and invasive management needs to be considered.

Applicability of Research to Practice

There is wide practice variability on the gynecological management of SJS/TENS patients with variable outcomes. Longitudinal studies on outpatients would better help create algorithms for patient management.
718 Estimation of Total Body Surface Area Burns in a Bilateral Above-Knee Amputee Patient
Authors: Peñarrieta-Daher Edgar , Treviño García Luis , Rodríguez Villa Paulina , Morales Ortiz Jorge , Leal-Gutierrez Jesus
Published: May 2023

Introduction

The burn injury extension estimate is necessary for the initial IV fluid resuscitation planning, however, current Wallace rule of nines, Lund & Browder charts as well as smartphone applications are based anatomical models with full body integrity.

The purpose of this paper is to accurately estimate the TBSA burned in a bilateral asymmetric above-knee amputee patient.

Methods

An amputation is defined as major amputation when the level is at or proximal ankle or wrist.

We present a case example of an 80-year-old patient with a past medical history of long-standing type 2 diabetes mellitus with inadequate metabolic control, left above-knee amputation seven years ago, as well as a contralateral asymmetric above-knee amputation seven months before hospital admission.

The patient was brought to the emergency department one hour after suffering burn injuries by fire at his shelter. Upon his arrival inhalational injury was ruled out, and at physical examination second and third-degree burns were noted circumferentially on both above-knee stumps, genitalia, right flank, lower abdomen and back, right hands and forearm, as well as left hand digits (Figure 1A-B).

Initial TBSA burned was estimated using the E-burn application yielding a 27% extension; however, this percentage would correspond to patient with full integrity of both lower limbs (Figure 2A)

Results

This is the first major amputee burned patient of 285 cases admitted for in-hospital treatment at our institution from March 2020 to October 2022.

After performing an online search on MEDLINE/Pubmed (keywords: TBSA, estimation, amputated) we found only one published paper in 2020 which presented a Correction Factor (CF) formula for a hypothetical burn patient with bilateral and symmetric fore-quarter amputation.

We estimated the amputated surface area (13.7%) with e-burn, to calculate the major amputee CF published in 2020 and test it on a clinical setting. By means of the following formula (Figure 1C): CF = 100 / (100 - % of amputated body part)

CF = 100 / (100 – 13.7)

CF = 100 / (86.3) = 1.15

Finally, the initial TBSA burnt was multiplied by the CF to adjust it accordingly to major amputations of the patient, as follows: Originally estimated TBSA burnt (27%) x CF (1.15) = 31.05 % (Figure 2B-C)

Conclusions

This case report serves as an example of the clinical application of the Correction Factor for major amputees burn patients which can be easily estimated with the aid of smartphone applications such as e-burn in mismatched bilateral amputations.

Applicability of Research to Practice

To our knowledge this is the first clinical application of the major amputee CF, which its simplified estimation by means of E-burn could be of use for burn centers with higher volume.
727 Development of an Acuity and Scheduling System for Wound Care
Authors: Salazar Elizabeth , Ruiz Alina , Ewing Amber , Terry Michelle
Published: May 2023

Introduction

Acuity systems have been used in nursing to quantify the care needed for each patient based on the patient’s nursing needs. The benefits for using an acuity system include avoiding over or understaffing and improving patient outcomes. To date no formal acuity system has been used to quantify the work associated with burn wound care. The purpose of this quality assurance project was to develop an acuity and scheduling system for burn patients and provide more effective and equitable staffing for burn wound care.

Methods

A wound care subgroup was formed by Unit Based Council to develop a point-based acuity scale for wound care. Numerical points were assigned for each body area dressed and wound care procedures such as surgical dressing take downs, moderate sedation, staple removal, wound vac change, wraps or casting, initial debridement, and discharge teaching (Fig. 1). Points were totaled and associated with a range of time: 1-5 points equals 45 minutes; 6-10 points equals 60 minutes; 11-15 points equals 75 minutes, and 16-20 points equals 90 minutes (Fig. 2). The total time of all dressing changes for the day based on the acuity system determines the RN and Tech staffing for wound care. After considering provider and therapy priorities, a schedule is posted in Microsoft Teams allowing for interdisciplinary collaboration and visibility on wound care scheduling.

Results

To date the acuity-based schedule has been used to schedule 500 consecutive dressings. Acuity based scheduling has helped to quantify the number of staff needed for wound care related to the amount of time needed each day. Prior to the initiation of this practice, wound care was assigned based on the number of patients instead of the workload required per patient leading to over or understaffing. The use of the acuity system has allowed the unit to predict the number of staff needed for wound care each day and adherence to the schedule with a margin of 30 minutes plus/minus was achieved.

Conclusions

Use of an acuity and scheduling system for burn wound care can improve staffing and will be a tool to quantify productivity.

Applicability of Research to Practice

Acuity systems and wound care scheduling can improve staffing for burn centers.
729 A Post-Pandemic Educational Program for New Burn Nurses
Authors: Klinkhamer Angela , Zynkian Megan , Lee Jeanne
Published: May 2023

Introduction

Transitioning into a nursing role within the burn center is clinically challenging and stressful. Due to the highly specialized nature of burn care, it is often difficult to find experienced nurses. Because of the shortage of experienced nurses, the burn center has been hiring many new graduate nurses. The COVID-19 pandemic greatly affected nursing schools, as clinical hours and experiences in the hospital were greatly reduced during peak outbreaks. Often, lab simulation and role playing were supplemented for clinical hours. In turn, nurses graduated with limited patient-nurse interactions and bedside experiences. From January 2020 through August 2022 our organization had an attrition rate of 27% for new graduate ICU nurses while the burn center saw a 25% attrition rate for new nurses. Our hypothesis is that an additional education program for new burn nurses will improve self-efficacy, knowledge and provide the support needed to promote long-term retention.

Methods

An educational program was created and implemented for two nursing cohorts. Twelve additional hours of hands-on skills and discussions were added over the course of the standard twelve-week orientation period. A pre and post exam consisting of identical questions was given to all participating staff to assess baseline knowledge and effectiveness of education. Discussions within each cohort identified learning needs and areas where additional support could be offered. The General Self-Efficacy Scale was used to assess pre and post program implementation. Results were analyzed using an unpaired t test.

Results

The average score in the eighteen-question pre-knowledge assessment exam was 72% and increased to 91% in the post-knowledge exam. The self-efficacy score increased from 1.68 to 3.36 (P value 0.0002). Based on self-efficacy results, nurses reported feeling more competent and less anxious about their new roles.

Conclusions

The post-pandemic population of new graduate nurses face a grave disadvantage when starting a new role due to limited clinical experiences, lack of available rotations and a reduction in clinical hours. This may set them up for failure due to decreased self-efficacy. Providing additional support and a proactive approach to educating new nurses has proven to be a valuable experience in the burn center.

Applicability of Research to Practice

Development of an educational program for new nurses was shown to improve self-efficacy and knowledge. Continuing this supplemental educational program for new nurses is beneficial to both new graduate and new burn nurses and has the potential to improve nursing retention.
730 Geographic Effects of Rural Burn Care Follow Up During the COVID-19 Pandemic
Authors: Bradshaw Evan , Garcia Liza , Anding Catherine , Pang Alan , Griswold John , Bharadia Deepak
Published: May 2023

Introduction

Follow-up appointments (FUAs) are crucial to monitor proper healing in burn patients. This study aims to determine if there is a predictive relationship between the distance a patient lives from the burn center and FUA attendance This study also aims to determine if the COVID-19 pandemic had any effect on FUA attendance at our burn center.

Methods

Data was collected from the Burn Registry of a rural, ABA verified Regional Burn Center on patients who were admitted for an inpatient stay and discharged from January, 2019 through December, 2020. For each patient, we recorded demographic factors, home zip code, TBSA, length of inpatient stay, and FUA outcome. We split the resulting cohort in two separate ways by FUA status and pandemic status based on if they did/did not attend followup and were admitted before 3/9/20 (pre-pandemic) or after 3/9/20 (intra-pandemic). Chi Square Tests were used to determine if the rate of followup differed across pandemic status. We then ran Mann-Whitney U Tests to compare all the variables across both pandemic status and FUA status.

Results

The cohort consisted of 511 patients. The pre-pandemic followup rate was 71.0% (n = 334) and the intra-pandemic followup rate was 71.2% (n = 177). This was not a statistically significant difference (Χ2 = 0.003, df = 1, p = 0.96). The next analysis compared the variables across pandemic status. The only significantly different variable between the groups was an increased percentage of 2nd degree burns in the intra-pandemic group (U = 24656.0, p = 0.018). The next analysis compared the variables across FUA status. Age, distance to the burn clinic, and amount of 3rd degree burns significantly differed across FUA status groups (U = 22789.0, p = 0.007; U = 19946.5, p = 0.000; U = 22738.5, p = 0.037, respectively), indicating the group that did follow up was younger, lived closer, and had more 3rd degree burns.

Conclusions

Furthermore, the results indicate that the distance a patient lives from our center is the highest predictive variable in determining whether or not a patient will attend followup.

Applicability of Research to Practice

This research is especially applicable to practitioners in rural environments or those evaluating the reasons for lack of follow-up in burn care.
731 Evaluation of PROMIS-10 Global Health Survey Implementation at a Regional Burn Center Clinic
Authors: Hunter Mary , Gaskins Devin , Hubbard Michelle , Carrougher Gretchen , Wiechman Shelley , Stewart Barclay , Chambers Mona , Gibran Nicole
Published: May 2023

Introduction

Patient-Reported Outcomes Measure System-10 (PROMIS-10) is a brief survey consisting of 10 items that evaluates patients’ global physical and mental health. PROMIS-10 was introduced into our burn clinic as a screening tool and serial measure of recovery. We aimed to assess the implementation of PROMIS-10 to improve its equitable use in outpatient clinics.

Methods

The PROMIS-10 was implemented in 2014 as part of a packet of other screening tools. The staff were trained in its use. Patients completed English-language surveys via paper/pen upon arrival at each of their burn clinic appointments while waiting to be roomed. Survey results were reviewed by clinic providers and addressed as part of routine care. Survey answers were entered into REDCap and merged with demographic and burn injury information. Data were collected and analyzed using univariate and bivariable statistics to evaluate equitable implementation.

Results

A total of 1,963 surveys were collected from 1,606 patients from January 2014 to December 2020 (Figure 1). After excluding patients with missing collection of survey and/or demographic data, our analysis included 1,072 patients. The mean number of surveys completed per visit was 0.53 (SEM=0.007) and 88% of patients completed 1 or more surveys. Patients who required intensive care during their index hospitalization or had an operation had higher mean surveys completed per visit (Highest Level of Care ICU=0.611 ± 0.02; Required an operation = 0.608 ± 0.015), whereas patients requiring an interpreter had lower mean surveys completed per visit (Required an Interpreter = 0.468 ± 0.031).

Conclusions

Although the majority of patients completed the PROMIS-10 during at least one clinic visit, there is significant room for improvement given our intent to use it as a screening tool for every encounter and metric of recovery progress over time. Focus on equity in completion is needed (e.g., coordinating interpreter-assisted completion, availability of translated forms, person-assisted completion for limited English proficiency, medical record integration for telemedicine and progress tracking). We did note that patients with markers of high burn severity (ICU stay, requiring an operation) had higher rates of survey completion per visit. This is a patient population in which serial evaluation is particularly helpful in monitoring recovery.

Applicability of Research to Practice

Use of PROMIS-10 can successfully be used as a screening and recovery progress metric in the outpatient setting. Equitable implementation should be assessed, and efforts to integrate such screening tools into the medical record should be considered.
733 Development of TeleBurn Utilizing Hospital Based EMR and Stroke Robot Photography
Authors: Bernal Nicole , McGuire Beth , Pezzopane Laura , Skornicka Susanna
Published: May 2023

Introduction

Our burn center is located in a state that takes referrals from rural areas up 160 miles away. Transfer to our often at capacity emergency department for burn wound care and to be discharged is an expense to the patient and the medical system.

Using existing transfer center nurses, the EMR system, and hospitals connected in the stroke network hypothesized we could create a TeleBurn program without additional equipment or resources. This was developed to expedite patient care and move the burn evaluation for smaller burns to the outpatient clinic from the emergency department. Calls were covered by the on-call trauma attending.

Methods

The TeleBurn program used 27 care connect hospitals in our stroke network. Calls were received through transfer center Figure 1. If the call was one where the physician was asking for opinion or possible follow up, the stroke robot was brought into the room, photographs taken and uploaded to EMR. A page/EMR message alerted call trauma attending physician. If the patient’s burn were small, they were set up for follow-up in clinic the next day in designate protected slots, if they needed surgery, admission for pain or wound care transfer, was arranged. The transfer center sent clinic staff message through EMR.

Results

Compared to previous year there was reduction of 3-10 ED visits per month and doubled new clinic visits in those same months. During the three-month pilot period, only one patient required admission when seen in clinic. Table 1. Our no show rate for protected slots was higher at 33% compared to no show rate of 12% for scheduled burn patients.

Conclusions

We demonstrated that TeleBurn triage can be done in a HIPPA compliant manor without having to purchase a new technology or platform. The development of a process with pictures and guaranteed followed up gave both the on call physician and transferring physician the confidence not to transfer a patent in middle of the night. More work is needed to determine why the no-show rate is high and how to adjust appointments to correct.

Applicability of Research to Practice

It is feasible to create a successful system that uses your EMR and limits additional steps for transferring physicians and on-call surgeon. Real time communication was utilized with the team to help vet issues quickly and allow for rapid feedback.
736 Burn Injuries During the Pandemic: Older Patients, Delays to Admission, and Longer Hospital Stays
Authors: Vuillier Jonathan , Rezwan Siam , Atayeva Rena , Cooney Carisa , Werthman Emily , Tiongco Rafael Felix , Ballou Jessica , Caffrey Julie
Published: May 2023

Introduction

The COVID-19 pandemic’s impact on school closures, workforce/employment status, and the enactment of stay-at-home orders may have resulted in changes in the incidence, mechanisms, and time to presentation for treatment of burn injuries. Given the need for prompt treatment of burn injuries to prevent worsening of the injury, infection, and/or critical illness, potential delays in burn treatment during the pandemic may have resulted in poorer patient outcomes. We hypothesize that burn patients demonstrated delays to presentation, changes in burn injury mechanisms, and increased mortality intra-pandemic compared to pre-pandemic.

Methods

We conducted a retrospective review of records from the burn registry of a tertiary urban burn center. Persons aged 0 to 99 presenting with a burn between March 2019 and March 2021 were included for evaluation (n=1524). Demographics, time to presentation, and admission type were compared for persons presenting pre-pandemic (March 11, 2019-March 10, 2020) to intra-pandemic cases (March 11, 2020-March 10, 2021). TBSA, length of stay, mechanism of injury, and final disposition were compared for inpatients presenting pre- to intra-pandemic. Chi-squared and Student’s t-test analyses were conducted for comparisons between the pre- and intra-pandemic groups; statistical significance was set at p< 0.05.

Results

Pre-pandemic, 777 persons presented to the burn center with 239 (30.8%) admitted; intra-pandemic, 747 persons presented with 260 (34.8%) admitted. Presenting patient mean age pre-pandemic was significantly lower than intra-pandemic (41 vs. 44 years, p=0.001), as well as mean time to admission (1.41 vs 2.46 days, p=0.04). There was no statistically significant difference in patient gender, race, ethnicity, or admission type pre- vs. intra-pandemic. For inpatient admissions (n=499), there was a significant increase in length of stay pre- vs. intra-pandemic (8.31 vs. 11.26 days, p=0.042); no significant changes in TBSA, mechanisms of burn injury, or disposition were found.

Conclusions

Our results indicate that patients who presented intra-pandemic were significantly older and had greater injury-to-presentation times than those who presented pre-pandemic. The pandemic did not seem to have a significant effect on burn TBSA, mechanisms of injury, or disposition. These results may have important implications for the role of telehealth in burn care and public health programs for burn prevention and treatment during times of stress on the healthcare system.

Applicability of Research to Practice

Analysis of pre- and intra-pandemic burn injuries enables explorations of how pandemics impact both the ability of patients to seek treatment and the impact of delays in seeking treatment. Such analysis lends itself well to exploring the vital role of public health advocacy, use of telehealth, and burn prevention campaigns during crises.
738 Access to Burn Care: A 10 Year Perspective of Burn Centers in the U.S.
Authors: Lovick Elle , Carter Jeffrey , Phelan Herbert , Kearns Randy , Phillips Bart , Hickerson William
Published: May 2023

Introduction

Only 2% of US hospitals have designated burn centers (BC), of which 57% are verified by the American Burn Association (ABA). Further, of the non-verified burn centers, it is unclear which ones meet requirements set by their state departments of health. This gap in knowledge of BC verification and/or designation status combined with the lack of an accurate, publicly available database to route patients and characterize BC resources creates challenges in burn care, especially in disaster preparedness. The goal of our study was to characterize the net effect of domestic BC openings and closings over the last decade on US burn resources and, thus, access to care.

Methods

Our group has recently created the National Injury Resource Database (NIRD), a comprehensive list of every US Level I and II trauma center and/or burn center. NIRD was created by culling these facilities from 1) the current ABA burn center directory, 2) the current ABA burn center regional map, 3) the American Hospital Association database, 4) the American College of Surgeons Committee on Trauma database, and 5) data from all 50 State Departments of Health. Redundant entries were omitted, and 100% of the remaining institutions were then personally contacted by one of the study investigators to confirm or clarify the status of each center as well as the resources listed in the various databases. The NIRD database was then compared to the ABA’s 2012 burn center directory to compare the number, identities, and characteristics of those US BCs which had either closed or opened in the intervening ten years.

Results

In 2012, there were 127 total BC, 63 of which were ABA verified. Currently, NIRD shows that there are 134 total BC recognized by the ABA, 76 of which are verified. Since 2012, 11 BC have been removed from the ABA’s burn center directory after either closing or failing to maintain ABA recognition, while 18 BC have been added. In the same time frame, there have been changes in BC verification status across the US, with 14 BC gaining ABA verification and 1 BC losing verification. In comparing the ABA’s current BC directory to their burn center regional map, we found variability in 18 centers across 15 states (CA, DC, IL, IN, KS, MD, ME, MI, MS, MO, NY, TN, TX, VA, VT), i.e., instances in which 1 or more BC found on the ABA’s BC regional map were not found on the ABA’s BC directory list.

Conclusions

The last 10 years have shown an upward trend in the number of US BC. Further, we found variability in the ABA’s online resources in 15 states, suggesting that their resources are outdated. NIRD can serve as a resource for the construction of publicly available real-time tools to aid in routing burn patients.

Applicability of Research to Practice

NIRD can serve as a resource for the construction of publicly available real-time tools to aid in routing burn patients.
744 Characteristics of Verified and Designated Burn Centers
Authors: Carter Jeffrey , Kearns Randy , Lovick Elle , Murata Erica , Phillips Bart
Published: May 2023

Introduction

Burn centers serve an essential role in providing specialized care for the injured. Professional societies (verify) and state agencies (designate) these facilities through a process that evaluates the resources, processes, and capabilities of each burn center. Over 90% of the level 1 or 2 trauma centers in the US and only around 50% of burn centers are verified. The goal of our study was to evaluate the variability of verified and designated burn centers and trauma centers in the US.

Methods

The Databases for Optimal Resources for Injury Care (DORIC) is a centralized database developed by the American Hospital Association, American College of Surgeons Committee on Trauma, American Burn Association, all fifty US states’ Departments of Health, and claims databases through a collaboration with BData, LSUHSC, Spectral MD, and UNO. Categorical data was assessed using Fisher’s exact while continuous variables were assessed with paired t-test and confidence intervals. The analysis included hospital and burn ICU bed count, hospital revenue, ED visits, discharges, and urban vs rural geography.

Results

The database includes 134 burn centers of which 75 were verified (56%), 91% were in an urban setting and 87% were co-located with a trauma center. Hospitals had a median of 492 staffed beds, 79,449 ER visits, and 18,437 discharges. Burn centers had a median of 11 burn ICU beds and 3,285 hospital days/year. Urban vs rural geography was not different between verified and designated burn centers (p=0.54). All categories of revenue were associated with burn center verification.

Conclusions

Our study demonstrates no significant difference with the hospital size, location (urban vs rural), ER volume, hospital beds, or burn ICU beds. Significant differences were identified with the rate of discharge and revenues which could be attributed to services, quality, or reimbursement. Given that only half of burn care occurs at verified burn centers, additional research is needed to better understand these significant differences.

Applicability of Research to Practice

A keen understanding of burn center characteristics is essential to serve the burn professionals that work at burn centers and the communities they serve.
753 Aquatic Therapy Improves Functional Outcomes in a Pediatric Burn Patient
Authors: Arango Maria , Schulman Carl
Published: May 2023

Introduction

Burn injuries in the pediatric population require extended recovery time due to changes in their respiratory function and musculoskeletal system (prolonged fascia damages and muscular weakness) leading to low physical and functional capacity. Other external factors contributing to poor outcomes are pain, psychosocial changes such as depression, self-esteem and body image. In the rehabilitation process there are different modalities and techniques for that can be used to enhance recovery. Aquatic therapy is a modality that facilitates movement. The buoyancy of the water supports body weight and reduces the load on painful joints. The density of the water forces the body upwards, the relatively high water temperature promotes muscle relaxation, and the hydrostatic pressure reduces the development of edema. We hypothesized that aquatic therapy would improve motor skill, respiratory function, and musculoskeletal functional capacity in pediatric burn patients.

Methods

This is a case comparison study comparing the functional outcome on a 6 y/o burned patient utilizing aquatic therapy compared with the same age patient that had traditional therapy in a regular play gym. Both patients had second degree burns TBSA 20 to 30% in the arms and face area, requiring autografts from chest/back and legs. The study treatment consisted of intensive interdisciplinary therapy in the pool for 90 minutes, one time per week for 8 months. The therapy involved games with physical demands to improve cardiorespiratory endurance, balance, postural control, body alignment, fine and gross motor skills, and the functional use of full range of motion, strength and dexterity. At completion of the aquatic program, Active Range of Motion measurements of the joints was performed using a goniometer and the Bruininks-Oseretsky Test of Motor Proficiency in order to evaluate functional improvements.

Results

Our results showed that the aquatic program increased motivation, respiratory capacity, achieved full AROM in all joints involved. The score in the Bruininks-Oseretsky Test of Motor Proficiency for each patient is shown in Table 1. It was demonstrated that the patient that did not use aquatic therapy as a modality did not regain full range and function compared to the aquatic therapy patient.

Conclusions

The use of aquatic therapy as a modality in pediatric burn patients can provide direct benefits such as gaining full AROM to participate in fine motor and gross motor functional activities and indirect benefits like motivation due to the engagement to learn to swim, play in the water and community reintegration.

Applicability of Research to Practice

The positive results of aquatics on this pediatric burn patient and the review of other studies support further development of an aquatic program as a positive rehabilitation modality.
771 Enzymatic Burn Wound Debridement: The Learning Curve
Authors: Mertz Tamara , Sen Sankhya , Mackie Ian
Published: May 2023

Introduction

The European Medicines Agency (MEA) approved the use of a proteolytic enzymatic debriding agent enriched in bromelain in 2012. It has become a widely used non-surgical treatment alternative for the debridement of deep partial thickness to full thickness thermal burns.

We will present our early experience with this product candidly. We will outline our sequential learning. Moreover, we will describe the pitfalls and lessons learned as well as demonstrate the evolution of our current practice guidelines.

Methods

This is a retrospective analysis of all patients treated with a bromelain based enzymatic debridement agent at a regional burn unit. 17 patients with a mean age of 44.53 years were treated with enzymatic debridement between April 2017 and April 2022. This period includes an 18 month pause where we did not use the product. We reviewed analgesia requirements, efficacy of debridement using the product, wound care post debridement (including the use of skin substitutes), skin grafting post application and overall outcomes.

Results

17 patients were treated during this period. Nine patients had burns involving less than 5% TBSA, three patients had burns between 5 and 15% TBSA and five had burns greater than 15% TBSA.

Of the 17 patients, 10 had the enzymatic debridement agent applied on the ward and seven had it applied in theatre. For the application of the product three patients had general anaesthesia, two had a combination of general and regional anaesthesia (e.g. spinal, axillary block), three had regional analgesia alone, seven received oral analgesia and ward based sedation and two received oral analgesia and ward based Methoxyflurane.

10 patients required skin grafting. One patient was treated with allograft post enzymatic debridement. One patient had their post enzymatic debridement wounds covered with Xenograft. The remainder had their post debridement wounds treated with dressings.

There were three cases where the proteolytic agent failed to debride the burns. In the skin grafted group, 1 patient had complete graft loss.

We will provide a narrative description and outline how each case contributed to the development of our current treatment algorithm.

Conclusions

We now believe that enzymatic debridement does have a real place within the armamentarium of burn wound excision with dermal preservation. Undoubtedly, there is a learning curve associated with its use. This must be considered by any service intending to adopt its use.

Applicability of Research to Practice

We support the use of bromelain enriched proteolytic enzymatic debriding agent in appropriate cases. With experience, it is likely to be useful in the management of many patients who sustain deep partial thickness to full thickness burns.
Tissues and mechanisms associated with Verticillium wilt resistance in tomato using bi-grafted near-isogenic lines
Authors: Oh Yeonyee , Ingram Thomas , Shekasteband Reza , Adhikari Tika , Louws Frank J , Dean Ralph A
Published: May 2023

Host resistance is the primary means to control Verticillium dahliae, a soil-borne pathogen causing major losses on a broad range of plants, including tomato. The tissues and mechanisms responsible for resistance remain obscure. In the field, resistant tomato used as rootstocks does not confer resistance. Here, we created bi-grafted plants with near-isogenic lines (NILs) exhibiting (Ve1) or lacking (ve1) resistance to V. dahliae race 1. Ten days after inoculation, scion and rootstock tissues were subjected to differential gene expression and co-expression network analyses. Symptoms only developed in susceptible scions regardless of the rootstock. Infection caused more dramatic alteration of tomato gene expression in susceptible compared with resistant tissues, including pathogen receptor, signaling pathway, pathogenesis-related protein, and cell wall modification genes. Differences were observed between scions and rootstocks, primarily related to physiological processes in these tissues. Gene expression in scions was influenced by the rootstock genotype. A few genes were associated with the Ve1 genotype, which was independent of infection or tissue type. Several were physically clustered, some near the Ve1 locus on chromosome 9. Transcripts mapped to V. dahliae were dominated by secreted candidate effector proteins. These findings advance knowledge of molecular mechanisms underlying the tomato–V. dahliae interaction.
Quantitative Value of Bacteria Associated with Leukocytes in Differential Diagnosis of Lower Respiratory Tract Infection in Children, in Comparison to Sputum Culture and Procalcitonin
Authors: Zhang Guoqiang , Yao Yihui , Gao Ying , Yu Xiaolu , Fang Jiabin
Published: May 2023

Background

The mortality and morbidity rates in children with lower respiratory tract infection (LRTI) remain high.

Objective

To describe the number of bacteria that is associated with leukocytes in differential diagnosis of bacterial, mycoplasma, and viral LRTI in children.

Methods

Sputum smears were Gram stained for counting single-morphology bacteria associated with leukocytes. The differential diagnostic values of bacterial number were assessed in children with LRTI.

Results

The area under the receiver operating characteristic (ROC) curve was 0.95 for bacterial number in the differential diagnosis of bacterial infection from mycoplasma and viral infections. The area under the ROC curve was 0.62 for procalcitonin and 0.94 for bacterial number in the differential diagnosis of bacterial infection from mycoplasma infection.

Conclusion

The number of bacteria associated with leukocytes in sputum was valuable and rapid in differential diagnosis of bacterial infection in children with suspected bacterial, mycoplasma, and viral LRTI.
Examining the performance of three ballast water compliance monitoring devices for quantifying live organisms in both regulated size classes (≥50 μm and ≥10–<50 μm)
Authors: Casas-Monroy Oscar , Brydges Torben , Kydd Jocelyn , Ogilvie Dawson , Rozon Robin M , Bailey Sarah A
Published: May 2023

A number of ballast water compliance monitoring devices (CMDs) have been made commercially available to verify the efficacy of ballast water management systems by quantifying the living organisms for both plankton size classes (≥50 μm and ≥10–<50 μm). This study aimed to examine whether new CMDs can provide a reliable indication of compliance regarding Regulation D-2 and to evaluate their performance for indicative analysis of organisms by assessing their accuracy (comparison to microscopy) and precision (comparison within measurement). Challenge fresh water samples were collected in four locations of Lake Ontario, Canada, whereas marine challenge water samples were collected around the Bay of Fundy, New Brunswick, Canada. Ballast water samples were collected from ships visiting several ports across Canada. Overall, accuracy was higher (>80%) in estimating organisms from prepared-challenge water (Ballast Eye and BallastWISE) than from ballast water samples (>70%) (B-QUA only). The sensitivity ranged from 50 to 100% for the ≥50 μm organism size class, whereas for the ≥10–<50 μm organism size class, it was higher for freshwater samples (>75%) than for marine samples (>50%). The performance of CMDs should be assessed under real-world conditions for a better understanding and to improve their use.
The incidence, impact, and risk factors for moderate to severe persistent pain after breast cancer surgery: a prospective cohort study
Authors: Chiang Daniel L C , Rice David A , Helsby Nuala A , Somogyi Andrew A , Kluger Michal T
Published: May 2023

Background

Few Australasian studies have evaluated persistent pain after breast cancer surgery.

Objective

To evaluate the incidence, impact, and risk factors of moderate to severe persistent pain after breast cancer surgery in a New Zealand cohort.

Design

Prospective cohort study

Methods

Consented patients were reviewed at 3 timepoints (preoperative, 2 weeks and 6 months postoperative). Pain incidence and interference, psychological distress and upper limb disability were assessed perioperatively. Clinical, demographic, psychological, cancer treatment-related variables, quantitative sensory testing, and patient genotype (COMT, OPRM1, GCH1, ESR1, and KCNJ6) were assessed as risk factors using multiple logistic regression.

Results

Of the 173 patients recruited, 140 completed the 6-month follow-up. Overall, 15.0% (n = 21, 95% CI: 9.5%—22.0%) of patients reported moderate to severe persistent pain after breast cancer surgery with 42.9% (n = 9, 95% CI: 21.9%—66.0%) reporting likely neuropathic pain. Pain interference, upper limb dysfunction and psychological distress were significantly higher in patients with moderate to severe pain (P < .004). Moderate to severe preoperative pain (OR= 3.60, 95% CI: 1.13–11.44, P = .03), COMT rs6269 GA genotype (OR = 5.03, 95% CI: 1.49—17.04, P = .009) and psychological distress at postoperative day 14 (OR= 1.08, 95% CI: 1.02—1.16, P = .02) were identified as risk factors. Total intravenous anesthesia (OR= 0.31, 95% CI: 0.10 – 0.99, P = .048) was identified as protective.

Conclusion

The incidence of moderate to severe persistent pain after breast cancer surgery is high with associated pain interference, physical disability, and psychological distress. Important modifiable risk factors were identified to reduce this important condition.
Boundary-work and social closure in academic recruitment: Insights from the transdisciplinary subject area Swedish as a Second Language
Authors: Ganuza Natalia , Salö Linus
Published: May 2023

This article explores practices of evaluation in academic recruitment in Swedish as a Second Language (SSL), an expanding and transdisciplinary subject area. As is common elsewhere, Swedish academia relies on a tradition of external expert review intended to ensure a meritocratic process. Here, we present an analysis of 109 written expert reports concerning recruitment to 57 positions in SSL during 2000–20. Because SSL lacks institutional autonomy, and is spread across several sub-disciplines in the humanities and social sciences, the material encompasses experts with diverse academic backgrounds. The SSL reports are broadly characterized by qualitative assessment. In contrast to other fields, the SSL experts seldom use quantitative proxy measures. Instead, they mainly rely on received conceptions of the boundaries of SSL as a means of justifying their inclusion and exclusion of candidates. This dominant regularity consists of attempts to define and delimit SSL and its core research areas, to locate the candidates in a core-to-periphery scheme with respect to these boundaries, and to rank them accordingly. This mechanism of social closure serves to restrict access to SSL to candidates with qualifications that conform to the experts’ own conceptions of SSL. As we show, the experts’ internally ambiguous conceptions of SSL tend to be constructed in relation to their own scientific habitus and investments. Beyond evaluating applicants’ possession of scientific capital, their distinctive style of reasoning around research qualifications and skills thus involves power-laden boundary-work, which leaves ample room for individual, yet habitus-specific arbitrariness.
Adherence to dietary guidelines, and the risk of developing rheumatoid arthritis: results from a nested case-control study
Authors: Bäcklund Rebecka Teresia , Drake Isabel , Bergström Ulf , Compagno Michele , Sonestedt Emily , Turesson Carl
Published: May 2023

Objectives

To examine the relationship between adherence to dietary guidelines and the risk of developing RA.

Methods

Participants in the Malmö Diet and Cancer Study (MDCS) cohort diagnosed with RA were identified through register linkage and validated in a structured review. Four controls per case were selected, matched for sex, year of birth, and year of inclusion in the MDCS. Diet was assessed at baseline (1991–1996) using a validated diet history method. A Diet Quality Index (DQI) based on adherence to the Swedish dietary guidelines including intakes of fibre, vegetables and fruits, fish and shellfish, saturated fat, polyunsaturated fat, and sucrose, was used. The associations between the DQI and its components and the risk of RA were assessed using conditional logistic regression analysis, adjusting for total energy intake, smoking, leisure time physical activity and alcohol consumption.

Results

We identified 172 validated cases of incident RA in the cohort. Overall adherence to the dietary guidelines was not associated with the risk of RA. Adherence to recommended fibre intake was associated with decreased risk of RA in crude and multivariable-adjusted analyses, with odds ratios (ORs) 0.60 (95% CI 0.39, 0.93) and 0.51 (95% CI 0.29, 0.90), respectively, compared with subjects with non-adherence.

Conclusions

Reaching the recommended intake level of dietary fibre, but not overall diet quality, was independently associated with decreased risk of RA. Further studies are needed to assess the role of different food sources of dietary fibre in relation to risk of RA and the underlying mechanisms.
Tumour-associated antigens in systemic lupus erythematosus: association with clinical manifestations and serological indicators
Authors: Zhong Ying , Liu Zhichun , Ma Jinlu , Zhang Lin , Xue Leixi
Published: May 2023

Objectives

To explore the relationship of tumour-associated antigens (TAAs) with the clinical manifestations and serological markers of SLE.

Methods

This was a retrospective study. Clinical data of SLE patients were extracted from the electronic medical records, including serum levels of TAAs such as alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), cancer antigen (CA) 19-9, CA125, CA15-3 and cytokeratin 19-fragments (CYFRA21-1). TAA positivity was defined as serum level exceeding the upper limit of the corresponding reference range.

Results

A total of 149 SLE patients (SLE group) and 149 age- and sex-matched healthy subjects (control group) were enrolled. Compared with healthy controls, the SLE group had higher positivity rates for CA19-9 and CYFRA21-1, and elevated serum levels of CA125, CA15-3 and CYFRA21-1. SLE patients with TAA positivity were older, had a higher prevalence of serous effusion, pericardial effusion, albuminuria and thrombocytopenia, and lower positivity rate for anti-dsDNA than patients without TAA positivity. The levels of serum creatinine (SCR), blood urea nitrogen, glutamic oxalate transaminase and 24-h urinary protein were also higher in SLE patients with TAA positivity, but platelet count and serum albumin levels were lower. On logistic regression, thrombocytopenia and SCR levels were identified as independent risk factors for TAA positivity. CA125 positivity rate and serum levels of CA125 were associated with SLE disease activity.

Conclusion

The positivity rates and serum levels of some TAAs were elevated in SLE, and thrombocytopenia and SCR levels were independent risk factors for TAA positivity.
FATCA and CRS: Recent EU judgment on public BO registers shines a light on the direction of travel
Authors: Noseda Filippo
Published: May 2023

This article builds on a previous piece published in Trusts & Trustees in 2022 entitled ‘FATCA, CRS and Public BO Registers: A report on the direction of travel—the next 12 months’. Since then, the Court of Justice of the European Union (‘CJEU’) struck down the EU's public registers of beneficial ownership following a small number of appeals brought before the district court in Luxembourg, prompting the EU to engage with data protection campaigners. The next 12 months are likely to be as momentous, with the High Court in London and the Austrian Federal Administrative Court due to hear cases on the data protection implications of the US Foreign Accounts Tax Compliance Act (‘FATCA’) and the Common Reporting Standard (‘CRS’). The author has been active in all these proceedings and in this article he reflects on the significance of the recent CJEU's judgment for FATCA and the CRS.
Wilson disease: a summary of the updated AASLD Practice Guidance
Authors: Alkhouri Naim , Gonzalez-Peralta Regino P. , Medici Valentina
Published: May 2023

Wilson disease (WD) is caused by autosomal variants affecting the ATP7B gene on chromosome 13, resulting in alterations in physiological copper homeostasis and copper accumulation. Excess copper clinically manifests in many organs, most often in the central nervous system and liver, ultimately causing cirrhosis and death. Often considered a pediatric or young adult disease, WD actually affects patients of all ages, and aging patients need to be regularly managed with long-term follow-up. Despite over a century of advances in diagnosis and treatment, WD is still associated with diagnostic challenges and considerable disability and death, in part due to delays in diagnosis and limitations in treatment. Standard-of-care treatments are considered generally effective when the diagnosis is timely but are also limited by efficacy, safety concerns, multiple daily dosing, and adherence. This expert perspective review seeks to facilitate improvements in the awareness, understanding, diagnosis, and management of WD. The objectives are to provide a full overview of WD and streamline updated diagnosis and treatment guidance, as recently published by the American Association for the Study of Liver Diseases, in a practical way for clinical use.