bluuebunny/crossref_metadata_2025 huggingface dataset:
Influence of Si content on thermal expansion characteristic of Al–Si alloys
Authors: Kim Yu-Mi , Choi Se-Weon , Hong Sung-Kil
Published: March 2020

The objective of this study was to find out how Si precipitation affects the linear thermal expansion behaviors of Al–Si alloys with various Si content. These Al–Si alloys were manufactured by gravity casting using 99.98 wt-% pure Al and 98.5 wt-% Si pellets. Solution treatment was carried out at 530°C for 10 h for each specimen. As-quenched specimens were subjected to microstructure observation and linear thermal expansion analysis. Si precipitation and additional linear thermal expansion occurred at lower temperature when Si content was increased to 9.5 wt-%. The activation energy of Si precipitation was also lower when Si content was higher. Eutectic Si reduced diffusion distance and acted as a nucleation site of dissolved Si atoms in the Al matrix during aging. These Si phases decreased Si precipitation temperature and activation energy of Si precipitation.
No thermoregulatory or ergogenic effect of dietary nitrate among physically inactive males, exercising above gas exchange threshold in hot and dry conditions
Authors: Fowler Rebecca , Jeffries Owen , Tallent Jamie , Theis Nicola , Heffernan Shane M. , McNarry Melitta A. , Kilduff Liam , Waldron Mark
Published: March 2020

The aim of this study was to determine the effect of five days dietary nitrate (NO3 −) consumption on exercise tolerance and thermoregulation during cycling in hot, dry conditions. In a double‐blind, randomised crossover design, 11 healthy males participated in an exercise tolerance test (Tlim) in the heat (35°C, 28% relative humidity), cycling above the thermoneutral gas exchange threshold, after five days of dietary supplementation, with either NO3 –rich beetroot juice (BR; ∼ 9.2 mmol NO3 −) or placebo (PLA). Changes in plasma [NO3 −] and nitrite [NO2 −], core and mean skin temperatures, mean local and whole‐body sweat rates, heart rate, perceptual ratings and pulmonary gas exchange were measured during exercise, alongside calorimetric estimations of thermal balance. Mean arterial pressures (MAP) were recorded pre‐Tlim. There were no differences in Tlim between conditions (BR = 22.8 ± 8.1 min; Placebo = 20.7 ± 7.9 min) (P = 0.184), despite increases in plasma [NO3 −] and [NO2 −] (P < 0.001) and a 3.8% reduction in resting MAP (P = 0.004) in the BR condition. There were no other differences in thermoregulatory, cardio‐metabolic, perceptual or calorimetric responses to the Tlim between conditions (P > 0.05). Dietary NO3 − supplementation had no effect on exercise tolerance or thermoregulation in hot, dry conditions, despite reductions in resting MAP and increases in plasma [NO3 −] and [NO2 −]. Healthy, yet physically inactive individuals with no known impairments in vasodilatory and sudomotor function do not appear to require BR for ergogenic or thermolytic effects during exercise in the heat.
USP22 promotes IRF3 nuclear translocation and antiviral responses by deubiquitinating the importin protein KPNA2
Authors: Cai Zeng , Zhang Meng-Xin , Tang Zhen , Zhang Qiang , Ye Jing , Xiong Tian-Chen , Zhang Zhi-Dong , Zhong Bo
Published: March 2020

USP22 is a cytoplasmic and nuclear deubiquitinating enzyme, and the functions of cytoplasmic USP22 are unclear. Here, we discovered that cytoplasmic USP22 promoted nuclear translocation of IRF3 by deubiquitianting and stabilizing KPNA2 after viral infection. Viral infection induced USP22-IRF3 association in the cytoplasm in a KPNA2-depedent manner, and knockdown or knockout of USP22 or KPNA2 impaired IRF3 nuclear translocation and expression of downstream genes after viral infection. Consistently, Cre-ER Usp22fl/fl or Lyz2-Cre Usp22fl/fl mice produced decreased levels of type I IFNs after viral infection and exhibited increased susceptibility to lethal viral infection compared with the respective control littermates. Mechanistically, USP22 deubiquitinated and stabilized KPNA2 after viral infection to facilitate efficient nuclear translocation of IRF3. Reconstitution of KPNA2 into USP22 knockout cells restored virus-triggered nuclear translocation of IRF3 and cellular antiviral responses. These findings define a previously unknown function of cytoplasmic USP22 and establish a mechanistic link between USP22 and IRF3 nuclear translocation that expands potential therapeutic strategies for infectious diseases.
Final report on supplementary comparison APMP.M.P-S9 in gas gauge pressure from 2 MPa to 20 MPa
Authors: Sainoo Likit , Khamnounsak Chaveng , Priruenrom Tasanee , Sabuga Wladimir , Ott Oliver , Manalo Radley F , Salazar Maryness I
Published: March 2020

This report describes the results of a supplementary comparison of gas pressure standards at three National Metrology Institutes - National Institute of Metrology (Thailand) (NIMT), Physikalisch-Technische Bundesanstalt (PTB) and National Metrology Laboratory of the Philippines (NMLPHIL) - carried out within the framework of Asia-Pacific Metrology Programme (APMP) in order to determine their degrees of equivalence at pressures in the range from 2 MPa to 20 MPa for gauge mode. The pilot institute was NIMT. The measurements were carried out from February 2016 to July 2016. All participating institutes used pressure balances as their pressure standards. A reference pressure monitor was used as a transfer standard. Characteristics of the transfer standard were evaluated at the pilot institute and then used for uncertainty estimations. After completing the comparison measurements, the transfer standard showed a less stable behaviour than expected, resulting in a significant contribution to the uncertainties of the results. The degrees of equivalence that were evaluated in terms of differences of the participant's results and the comparison reference values divided by their expanded uncertainties (k=2) are all within the unity. This demonstrates equivalence of the compared standards on the uncertainty level, which is unfortunately dominated by the uncertainty of the transfer standard.

Main text

To reach the main text of this paper, click on Final Report. Note that this text is that which appears in Appendix B of the BIPM key comparison database kcdb.bipm.org/.

The final report has been peer-reviewed and approved for publication by the CCM, according to the provisions of the CIPM Mutual Recognition Arrangement (CIPM MRA).
Volume comparison at 10 μL, 100 μL and 1000 μL—calibration of micropipettes. Volume comparison at 10 mL—calibration of burette
Authors: Rurua Irma , Batista Elsa
Published: March 2020

This report describes the results of international comparison within COOMET.M.FF-S8 (also known as supplementary comparison COOMET.M no. 767/GE/18). The comparison measurements between the two participants GEOSTM (pilot laboratory) and IPQ started in August 2018 and finished in December 2018.

Main text

To reach the main text of this paper, click on Final Report. Note that this text is that which appears in Appendix B of the BIPM key comparison database kcdb.bipm.org/.

The final report has been peer-reviewed and approved for publication by the CCM, according to the provisions of the CIPM Mutual Recognition Arrangement (CIPM MRA).
Analyzing the state of high-density areas in Japan after redevelopment projects
Authors: Tomita K , Kajita Y
Published: March 2020

Japan has many high-density residential areas that are prone to disasters. Therefore, the Ministry of Land, Infrastructure, Transport, and Tourism has conducted various projects to improve these areas. Housing environment issues have also become a major issue. Consequently, this study considers the activities in the redevelopment project and the issues that emerge afterward in the Setagaya ward (Tokyo), where the high-density area redevelopment was conducted. A result is the increase of young people and households in the area although the number of old people is still increasing. However, in the Setagaya area, a comparison of the population density and the green area ratio in 2011 and 2016 shows that the green area ratio increased although the population density in 2016 was higher than in 2011. This occurred due to the redevelopment of the ruins of the National Children’s Hospital into a condominium in 2008 and the efforts to achieve a green rate area ratio of 33% in Setagaya Ward by 2032. Green space has various functions in cities including in disaster prevention. As Japan is prone to disasters, the provision of green space is crucial.
An analysis of the spatial phenomena of women in Cigondewah Fabric Centre, Bandung, Indonesia
Authors: Agustina I H , Lingga N
Published: March 2020

The Bandung City government has established the Cigondewah fabric centre as a strategic commercial location in Bandung. This policy leads to the conversion of the settlement area into a commercial area, which creates spatial limitations for women in this area. Yet, it vital to consider the subject of space as the sustainability of the environment depends on human as the subjects in the space. In the case of Cigondewah fabric centre, the government should consider women because women experience space differently to men. Men can freely adapt to changes in space but women should be given more freedom. This is the case because women have specific physical values and religious limitations affect cultural norms.The objective of this paper is to reconstruct the spatial phenomena of women in Cigondewah. This study uses a qualitative method with an inductive approach based on several established spatial theories. Based on the findings, the study proposes a zoning classification that reflects the spatial phenomena of the women. Moreover, the paper proposes policy recommendations regarding the spatial conversion to have more consideration for women as subjects of space.
Counting elliptic curves with an isogeny of degree three
Authors: Pizzo Maggie , Pomerance Carl , Voight John
Published: March 2020

We count by height the number of elliptic curves over

Q

\mathbb {Q}

that possess an isogeny of degree

3
3

.
Orthogonal polynomials in and on a quadratic surface of revolution
Authors: Olver Sheehan , Xu Yuan
Published: March 2020

We present explicit constructions of orthogonal polynomials inside quadratic bodies of revolution, including cones, hyperboloids, and paraboloids. We also construct orthogonal polynomials on the surface of quadratic surfaces of revolution, generalizing spherical harmonics to the surface of a cone, hyperboloid, and paraboloid. We use this construction to develop cubature and fast approximation methods.
The family of perfect ideals of codimension 3, of type 2 with 5 generators
Authors: Celikbas Ela , Laxmi Jai , Kraśkiewicz Witold , Weyman Jerzy
Published: March 2020

In this paper we define an interesting family of perfect ideals of codimension three, with five generators, of Cohen-Macaulay type two with trivial multiplication on the

Tor
\operatorname {Tor}

algebra. This family is likely to play a key role in classifying perfect ideals with five generators of type two.
The Y-chromosome F haplogroup contributes to the development of Barrett’s esophagus-associated esophageal adenocarcinoma in a white male population
Authors: Westra W M , Rygiel A M , Mostafavi N , de Wit G M J , Roes A L , Moons L M G , Peppelenbosch M P , Ouburg S , Morré S A , Jacobs M , Siersema P D , Repping S , Wang K K , Krishnadath K K
Published: March 2020

Barrett’s esophagus (BE) is a metaplastic condition of the distal esophagus, resulting from longstanding gastroesophageal reflux disease (GERD). BE predisposes for the highly malignant esophageal adenocarcinoma (EAC). Both BE and EAC have the highest frequencies in white males. Only a subset of patients with GERD develop BE, while <0.5% of BE will progress to EAC. Therefore, it is most likely that the development of BE and EAC is associated with underlying genetic factors. We hypothesized that in white males, Y-chromosomal haplogroups are associated with BE and EAC. To investigate this we conducted a multicenter study studying the frequencies of the Y-chromosomal haplogroups in GERD, BE, and EAC patients. We used genomic analysis by polymerase chain reaction and restriction fragment length polymorphism to determine the frequency of six Y-chromosomal haplogroups (DE, F(xJ,xK), K(xP), J, P(xR1a), and R1a) between GERD, BE, and EAC in a cohort of 1,365 white males, including 612 GERD, 753 BE patients, while 178 of the BE patients also had BE-associated EAC. Univariate logistic regression analysis was used to compare the outcomes. In this study, we found the R1a (6% vs. 9%, P = 0.04) and K (3% vs. 6%, P = 0.035) to be significantly underrepresented in BE patients as compared to GERD patients with an odds ratio (OR) of 0.63 (95% CI 0.42–0.95, P = 0.03) and of 0.56 (95% CI 0.33–0.96, P = 0.03), respectively, while the K haplogroup was protective against EAC (OR 0.30; 95% CI 0.07–0.86, P = 0.05). A significant overrepresentation of the F haplogroup was found in EAC compared to BE and GERD patients (34% vs. 27% and 23%, respectively). The F haplogroup was found to be a risk factor for EAC with an OR of 1.5 (95% CI 1.03–2.19, P = 0.03). We identified the R1a and K haplogroups as protective factors against development of BE. These haplogroups have low frequencies in white male populations. Of importance is that we could link the presence of the predominantly occurring F haplogroup in white males to EAC. It is possible that this F haplogroup is associated to genetic variants that predispose for the EAC development. In future, the haplogroups could be applied to improve stratification of BE and GERD patients with increased risk to develop BE and/or EAC.
T5 Preliminary Analysis of a Phase 3 Open-label, Controlled, Randomized Trial Evaluating the Efficacy and Safety of a Bioengineered Regenerative Skin Construct in Patients with Deep Partial-thickness Thermal Burns
Authors: Holmes James H , Shupp Jeffrey W , Smith David J , Joe Victor C , Carson Joshua S , Litt Jeffrey , Kahn Steven , Short Tracee , Cancio Leopoldo C , Rizzo Julie A , Carter Jeffrey E , Foster Kevin N , Gibson Angela
Published: March 2020

Introduction

Autograft (AG) is the standard of care for treatment of severe burns. While AG provides effective wound closure (WC), the procedure creates a donor-site wound prone to dyspigmentation, infection, scarring, and pain. In a phase 1b trial, no deep partial-thickness (DPT) wound treated with a bioengineered regenerative skin construct (BRSC) required AG by Day 28 and WC at the BRSC site was achieved in 93% of patients by Month 3 (Holmes et al 2019). This phase 3 study evaluated the efficacy and safety of this BRSC in patients with DPT burns.

Methods

This phase 3 study (NCT03005106) enrolled patients aged ≥18 years with 3–49% total body surface area (TBSA) thermal burns on the torso or extremities. In each patient, two DPT areas (≤2,000 cm2 total) deemed comparable following excision were randomized to treatment with either cryopreserved BRSC or AG. Coprimary endpoints were 1) the difference in percent area of BRSC treatment site and AG treatment site autografted at 3 months and 2) the proportion of patients achieving durable WC of the BRSC treatment site without AG at 3 months. Safety assessments were performed in all patients. Efficacy was analyzed at 3 months and safety and scar follow-up continues to one year.

Results

A total of 71 patients were enrolled (mean [SD] age 44 [16] years; mean [SD] %TBSA 12.0 [8.4]). By Month 3, 4.3% (SD 21.6%) of all BRSC-treated area required AG compared with an additional regrafting of 2.1% of all AG-treated area (total 102.1% SD 13.1%; P< .0001). Three patients subsequently required AG at their BRSC site, 2 of whom also required it at their AG sites; Durable WC without autografting at the BRSC treatment site was achieved at Month 3 in 83% of patients compared with 86% of patients at the AG site. The most common BRSC-related adverse event (AE) was pruritus, occurring in 11 (15%) patients. All BRSC-related AEs were mild or moderate in severity.

Conclusions

This phase 3 study achieved both coprimary endpoints, including significant autograft sparing and durable WC in DPT burns. This BRSC may offer a new treatment for severe burns to reduce or eliminate the need for AG.

Applicability of Research to Practice

This BRSC has shown clinical benefit in patients with DPT thermal burns, potentially mitigating donor site morbidity.

External Funding

Stratatech, a Mallinckrodt Company; Funding and technical support for the Phase 3 clinical study were provided by the Biomedical Advanced Research and Development Authority (BARDA), under the Assistant Secretary for Preparedness and Response, within the U.S. Department of Health and Human Services, under Project BioShield Contract No. HHSO100201500027C.
21 Racial Disparities in Outcomes After Burn Injury in a Universally Insured Military Population
Authors: Castillo-Angeles Manuel , Burns Christopher J , Kubasiak John , Riviello Robert , Salim Ali , Nitzschke Stephanie
Published: March 2020

Introduction

In our healthcare system, racial disparities are estimated to account for more than 83,000 deaths and an average of more than $57 billion per year. These disparities have been well described in the surgical and trauma setting. Lack of insurance has frequently been blamed for the persistence of racial disparities in healthcare. The objective of the current study was to determine whether racial disparities in outcomes exist in a universally insured population of military-/civilian-dependent burn patients.

Methods

The 2006–2014 TRICARE military insurance database was queried for patients 18–64 years, who had a diagnosis of thermal burns. The Department of Defense Military Health System provides full insurance coverage for active/reserve/retired members of the Armed Services and their dependents. Basic demographic data and clinical characteristics were obtained. Our main outcome was in-hospital mortality. Multivariable logistic regression models were built to determine the association between race and the primary outcome.

Results

A total of 6,206 patients with diagnosis of burn injury were included: 69.7% white, 13.4% black, 6.8 % Hispanic, and 10% other. Median age was 29 years (IQR 23 - 40), and 63.1% were female. Overall mortality was 1.03%. In unadjusted analysis, there was no significant association between race and mortality (p=0.963). After multivariate analysis, no significant differences were found among racial minorities relative to racially white patients. Even though not significant, black patients had lower odds of mortality (OR 0.49, 95% CI 0.18 – 1.32) and Hispanic patients had higher odds (OR 1.33, 95% CI 0.39 – 4/52) when compared to white patients.

Conclusions

Risk-adjusted analysis did not show a significant difference in mortality among minority burn patients when compared to white patients. Our findings show that in a population with universal insurance and virtual equal access to care, racial disparities are mitigated. This data will help to the development of disparities interventions and its applicability nationwide.

Applicability of Research to Practice

The apparent mitigation of racial disparities among universally insured burn patients reinforces the association of insurance and access to care to outcomes in healthcare.
33 Effectiveness of Caregiver-oriented Transitional Care Program (CTCP) in Promoting Preparedness of Caregivers for Home Care of Burn Patients
Authors: Dualan Jun Jun A
Published: March 2020

Introduction

Unpreparedness of caregivers of burn patients can result to several complications at post-discharge period (Zwicker, 2010; AHRQ, 2012). Some burn centers in resource-scarce countries had documented several burn morbidity and mortality that occurred post hospital discharge. Psychological conditions, contractures, infection and even death are just some of the complications. One of the current trends in burns involves sending patients home with a burn dressing and following them up as outpatients for wound inspection. This could significantly reduce cost of hospitalization with shortened hospital stay and allows burn units to accommodate the overflow of acute and complex cases for admission. Although there are advantages in early discharge, this approach requires a change in the health teaching method and contents since hospital-to-home transition is expedited. Considering this dilemma, the investigator developed the CTCP to address the gap in transitional care of burns. This study aimed to compare the preparedness of caregivers before and after CTCP; and compare caregivers’ handwashing competency, wound dressing competency and medication administration hassle before and after CTCP.

Methods

One-group pre-and-posttest quasi-experimental design was used to study thirty adult caregivers of burn patients that were recruited via convenience sampling in a burn center between November 2017 to March 2018. CTCP was conducted in three sessions with the aid of videos and written instructional materials. Caregivers were evaluated in terms of preparedness (primary outcome) and handwashing competency, wound dressing competency and medication administration hassle (secondary outcomes). All measurement instruments were content valid and reliable.

Results

At alpha 0.05, data analysis revealed statistically significant results supporting the use of CTCP. Preparedness (p< 0.001), handwashing competency (p< 0.001), wound dressing competency (p< 0.001) and medication administration hassle (p< 0.001) improved after receiving the structured teaching intervention.

Conclusions

The study supported the relevance of the interventions to prepare caregivers for home care of burn patients to help prevent potential complications after hospital discharge. This is therefore recommended to be adapted by burn units that recognize primary caregivers as extended team members.

Applicability of Research to Practice

Since there is a limited evidence in nursing discharge education programs specific to burns, the results generated from this study can help practitioners effectively prepare caregivers for home care of burn patients as educational intervention is supported with strategies that increase learning retention.
36 Developing Burn Specific Documents in the Electronic Medical Record
Authors: Gabehart Kari , Tuvell Sara , Cook Christina L , Roggy David , Sood Rajiv
Published: March 2020

Introduction

The challenge with burn documentation needs in electronic medical record systems is recognized and often limited in the foundation of commercial electronic systems. In October 2016, our institution transitioned to a new all-inclusive electronic medical record. The transition to this new Electronic Medical Record (EMR) afforded us the opportunity to develop and build burn specific documentation needs in the new EMR system. In this paper, we share our experiences and the keys to our successful builds to streamline burn patients’ documentation and information.

Methods

In January 2013, the EMR build team was composed of corporate contractors, dedicated clinical staff from all areas of the hospital that transitioned to the build team, and private contractors experienced in the EMR build process. To our great fortune, our burn team was provided access to four dedicated build team members that worked specifically on meeting our burn team documentation needs. With high level collaboration our team was able to assess foundation abilities of the new system, identify gaps to burn care and collaboratively create and build automated documents to meet our burn needs. In October 2016, the EMR system was implemented with our burn specific documents, flowsheets, and reports.

Results

Through working with our dedicated build team, we were able to create an electronic Lund-Browder Chart with an avatar that is completed with each admission by our medical team. We developed a fluid resuscitation flowsheet that is documented in real-time; displays fluid resuscitation goals; displays urine output goals. The creation of a standardized wound care note template was necessary as the wound template within the existing EMR system was too cumbersome. Burn wound photo-documentation to include inpatient, outpatient, intra-operative and emergency department needs automatically uploads into the patient’s medical record from an encrypted portable handheld device connected to the EMR. Burn specific reports were developed to meet the specific needs of inquiry whether it is for performance improvement or research. Additionally, the same EMR is used in all phases of care to include the burn clinic which allows for ease and continuity of care.

Conclusions

An EMR that is all-inclusive has benefitted our team and patient safety by streamlining the review and documentation of information. Having specific and dedicated EMR build specialist allocated to focusing on the needs of the burn unit was invaluable in the build, implementation, and maintenance phases. We continue to work with our EMR specialist to improve processes and documentation practices that impact patient outcomes. Our burn EMR specialist meets with the burn team on a monthly basis to evaluate and assess ongoing needs to further outcomes.

Applicability of Research to Practice

Within this presentation, we will share our journey, challenges, and successes.
37 Identifying Vulnerable Children: Burn Pediatric Warning Scores and ICU Designation
Authors: Greenway Andrew , Heffernan Jamie , Xuereb Kevin , Houng Abraham , Sun Carolyn
Published: March 2020

Introduction

Pediatric Early Warning Scores (PEWS) facilitate the identification of non-ICU pediatric patients at risk for deterioration. Limited studies exist to describe the utility of Burn specific PEWS (bPEWS) in the early identification of clinical vulnerability. The purpose of this retrospective chart review was to associate a bPEWS assessment value with a need for elevation to an ICU level of care for the burn-injured child.

Methods

A retrospective chart review of all non-mechanically ventilated (nMV) pediatric patients admitted to the burn service from July 2013 to May 2016 (n=709). Data included bPEWS scores, age, total body surface area (TBSA) burn and hospital length of stay (LOS). A pediatric level of care (PLC) designation, instituted as a model of care delivery following this study, utilizes bPEWS to categorize patients by acuity. Patients are grouped by their highest bPEWS: a) unstable (bPEWS > 8; b) watchers (bPEWS 5–7); and c) stable (bPEWS < 5). This study retroactively utilizes this framework.

Results

709 patient charts yielded 12,642 bPEWS data points. 37 patients (0.53%) scored > 8 during their hospital stay. Patient age was not statistically significant, a=2.4 years, b=3.25, and c=2.3(F=0.64, p = 0.53). More secondary diagnoses were present in the a) unstable cohort (59%) than either the b) (26. 6%) or c) (20%); (c2 = 6.3, p = 0.02 and p < 0.01). There was a statistically significant difference in the number of patients in the unstable cohort versus the watcher and stable cohorts combined (c2 = 13.21, p < 0.01). Patient transfer to the pediatric ICU (PICU) occurred in 10.8% of the a) unstable group and none of the watcher or the stable cohorts (b, c), (p=0.02). Pediatric critical intensivist consults occurred in 19% of the a) unstable patients but not in either the watcher or the stable patients (p < 0.01). The average LOS was 18.1 days in the a) unstable group, 9.41 days in the b) watcher group, and 6.06 days for the c) stable group, (F=19.20, p < 0.01). TBSA burn was larger for the unstable group (12.5%), versus 5.74% for watcher patients, and 2.5 % for stable patients, (F=9.70, p < 0.01). On average, the peak bPEWS scores occurred hospital day 3.27 in the unstable group, 2.58 in the watcher group, and day 1.88 in the stable status group, (NS) (F=0.88, p = 0.42). There were no mortalities.

Conclusions

This retrospective review captures the infrequent experience of significant clinical deterioration in the nMV pediatric burn population reflected through the bPEWS lens. There appears to be a relationship between high bPEWS scores, burn size, presence of a secondary diagnosis, and increasing LOS. This study supports the designation of these patients to higher levels of care. This bPEWS driven paradigm presently results in adjusted nursing staffing ratios, frequency of assessment, and mandated collaborative medical practice patterns.

Applicability of Research to Practice

Directly Applicable.
38 A Retrospective Review Evaluating the Institution of Nurse Clinic Visits for the Treatment of Burn Patients Being Managed at Home
Authors: Solis-Gonzalez Stacy , Osborn Suzanne , Sirrine Robert P , Richey Karen J , Foster Kevin N
Published: March 2020

Introduction

Most burn injuries can be managed at home, however appropriate follow up care is vital to prevent complications. Our center developed an outpatient dressing and care algorithm aimed at improving patient outcomes and optimizing the use of healthcare providers. The algorithm consisted of scheduling patients discharged home from the burn emergency department with a nurse visit (NV) within 3 days of discharge and a provider visit (PV) 1 week later. All NV could be converted to PV prn. The purpose of this study was to evaluate the effectiveness and safety of our nurse clinic visits.

Methods

This was a retrospective study of outpatients managed using the new care algorithm over a 1-year period. Patients whose NV was converted (CV) to a PV were compared to those who were not converted (NCV). Basic descriptive statistics were calculated.

Results

The charts of 259 patients scheduled for NVs were reviewed, mean age was 24.3 years and 51% were male. The population consisted primarily of Caucasians (47%) and Hispanics (35%). Most patients had a payor source with private insurance (40%) and Medicaid (31%) being the most common. Initial presentation to the burn ED was 1.56 days post injury, mean TBSA was 1.58% and most injuries involved the hands (36%) and arms (28%). The most common mechanism was scald (56%) followed by contact (28%). The most common dressing was petroleum gauze (41%) followed by silver impregnated foam (39%). NVs were converted to PV for 16% of the population. The most common reason for conversion was discharge from clinic (33%), followed by worsening (24%), therapy needs (24%) and change in dressing (19%). When CV patients were compared to NCV there were no significant difference in age, gender, past medical history, burn history (time to presentation, TBSA, mechanism, area of injury) or dressing type with the exception of enzymatic debriders (p=.0226). Native Americans (p=0.0257) and patients with Workman’s Compensation (p=0.026) were more likely to be converted to a PV. Hispanic patients were less likely to be converted to PV (p=.0357). The charges for NV ranged from $120-$185/visit with an average reimbursement of $60.88.

Conclusions

Overall compliance with the scheduling of nurse visits was poor. However, when scheduled per the algorithm, nurse visits were safe and effective, decreasing provider workload while still allowing for patients to be seen in a timely manner.

Applicability of Research to Practice

Ongoing education and monitoring of compliance is needed to further evaluate the safety and utility of nurse visits.
39 Nurses Can Resuscitate
Authors: Cooper Cheryl , Cochran Amalia , Coffey Rebecca
Published: March 2020

Introduction

Fluid resuscitation in the first 48 hours post burn is crucial in the management of burn shock. Hourly titration of fluids is needed to avoid complications of over or under resuscitation which can increase morbidity and mortality. Historically these titrations have been driven by the burn physician; we hypothesized that given protocols with specific resuscitation parameters the burn nurse can accurately resuscitate the burn patient without complications.

Methods

This quality improvement project at our ABA verified adult Burn Center tracked performance of a nurse-driven protocol for all inpatients with burns who underwent formal fluid resuscitation. Education regarding the nursing-driven protocol was provided to 90 surgical intensive care nurses. Badge buddies with both the Parkland formula and the Modified Albumin formula were made for the staff. Burn order sets were updated to reflect burn resuscitation guidelines with fluid adjustment parameters. A 48-hour data resuscitation data collection tool was developed by the burn physicians and nurses and all resuscitations were reviewed in real-time and in burn leadership meeting to identify opportunities for improvement. Follow up and education reinforcement was done in real time by the clinical nurse specialist following each burn resuscitation.

Results

Over a one-year period, 23 patients’ resuscitations were tracked and reviewed by the burn quality team. One patient was excluded because of early transition to comfort care. After the initial three tracked resuscitations, the data collection tool was evaluated and modifications made to more effectively capture relevant findings. Mean age of patients was 45.1 (18–82) with a mean TBSA burn injury of 32.5 (15–42.5) In the first 24 hours patients (n=22) received a mean volume of 3.47 ml/kg/%TBSA (0.66 – 8.39) with a mean urine output of 0.95 mL/kg/hr (0.30 – 2.16 ml/kg/hr). For patients who remained on resuscitation during the second 24 hours (n = 16), they received a mean volume of 2.68ml/kg/%TBSA (0.56- 8.44) and had a mean urine output of 1.31 mL/kg/hr (0 .30–2.16). There were no complications related to fluid administration. Appropriate hourly fluid adjustments were made in 21 of the 22 patients. The one patient who did not have fluids titrated appropriately was attributed to resident physician education because the resident failed to provide the burn order set that includes the fluid resuscitation protocol.

Conclusions

Using a multidisciplinary approach and preparatory and real time education processes, burn nurses can successfully guide burn resuscitation. Providing education and follow up in real time can improve the process.

Applicability of Research to Practice

The use of nurse-driven protocols can improve outcomes for burn patients.
60 Contact Hand Burns in Children: Still a Major Prevention Need
Authors: McBride Jaclyn M , Romanowski Kathleen S , Sen Soman , Palmieri Tina L , Greenhalgh David G
Published: March 2020

Introduction

Since toddlers explore with their hands, contact burns continue to be a major pediatric problem. The purpose of this report is to review a pediatric burn unit’s 8-year experience with contact burns of the hand.

Methods

After IRB approval, a review of pediatric contact hand burns that occurred between 2006–2014 was performed. We examined the causes and outcomes in pediatric contact hand burns in a single pediatric burn program.

Results

In the 8-year span, 535 children suffered contact burns to the hand (67 per year). The majority suffered hands burns from an oven or stove (120). The other etiologies included burns from a fireplace (76), clothing iron (65), curling or straightening iron (50), and firepit or campfire (46). The mean age at time of injury was 2.62 years old, with a range of 2 months old to18 years old. Male children (339) typically burned their hands more than females (197). Locations of injury included the palmar surface, dorsal surface, fingers tips/thumb, wrist or a combination of several different areas. Most children burned the palmar aspect of their hand (384) compared to the dorsal aspect (61). These burns typically cover small total body surface areas (mean 1.08% TBSA), with only 2% of burns comprising >5% TBSA. Approximately, 84% of these patients did not need surgery, but 86 (16%) had skin grafting (usually full-thickness) and 26% needed a secondary surgery. Of those that needed more than two, the average number of procedures was 3.6. Approximately 4.1% of patients needed a tertiary surgery. Causes for tertiary surgeries included contractures and graft loss. Out of twenty-two patients that needed a third surgery, 59% were due to graft loss and 41% were due to contractures.

Conclusions

Contact burns to the hand continue to be a major problem for toddlers. Children are most likely to burn themselves on an oven or stove, fireplace, clothing iron or curling/straightening iron. The palmar surface of the hand is the most likely site. While most children do not require surgery, approximately 16% require grafting. A significant number of those patients need reconstructive surgery. Clearly, current prevention efforts have failed to reduce these injuries.

Applicability of Research to Practice

Palm burns are common in young children. Efforts should focus on preventing these injuries.
69 Outbreak of Carbapenem-polymyxin-quat-resistant Acinetobacter Baumannii Associated with Mafenide Acetate Shortages: An Interdisciplinary Approach to Eradication
Authors: Fleming Irma D , Tang Carla , Remington Lois , Lewis Giavonni
Published: March 2020

Introduction

In the wake of Hurricane Maria, many US hospitals experienced massive drug shortages requiring substitution with alternative therapies. Our regional center experienced an increased incidence of Carbapenem-Polymyxin-Quat-Resistant Acinetobacter baumannii(CPQRA) infections, compared to a previous year of no infections. Here we describe a successful interdisciplinary approach to its eradication.

Methods

We conducted a retrospective review of CPQRA outbreaks for November and December 2018 in the burn ICU. De-identified data was collected and analyzed. In collaboration with the state’s department of health and epidemiology section, whole-genome sequencing was carried out on bacterial isolates. In addition, we instituted adenosine triphosphate (ATP) monitoring on all surfaces, a process of rapidly measuring actively growing microorganisms.

Results

Resistant Acinetobacter was isolated from five ICU patients, two of whom died with CPQRA bacteremia, producing a case-fatality rate of 40%. The two cases that died both suffered traumatic injuries with multiple fractures in addition to an average TBSA of 58%.Non-fatal cases suffered no other traumatic injuries and had an average TBSA of 51%.During this period, genitourinary irrigant (neomycin-Polymyxin B) and polymyxin ointment were the primary topical agents for wound care. Whole genome sequencing revealed a qacEdelta1 positive strain and identified the primary source as a patient that returned from a long-term care facility carrying the converted A. Baumannii infection. ATP testing also showed increased levels in patient rooms and surgical suite.

Conclusions

As a result of these findings, we achieved eradication by developing new and reinforcing traditional practices of infection control. This included UV light therapy to all ICU rooms and surgical suite, oversight of environmental services procedures, rigorous enforcement of hospital infection control procedures, auditing hand hygiene, increased efforts in antibiotic stewardshipand discontinuing Polymyxin containing topicals. By January 2019 there were no new cases of CPQRA in the ICU. This study shows that the resistance and rapid spread of CPQRA can be controlled with the cooperation of hospital staff, environmental services, infection control, pharmacy and the state’s department of health. With the coordinated efforts of all parties, we were able to successfully eradicate a virulent and fatal resistant A. baumannii strain.

Applicability of Research to Practice

Describe an approach to eradicating resistant organisms and provide a roadmap to characterize the source, implement control measures to terminate an outbreak, and institute preventive measures.
70 Chlorhexidine Gluconate for Burn Wound Cleansing: Reduction in Multi-drug Resistant Organism Acquisition
Authors: Miller-Willis Kelsey L , Thomas Mini , Joe Victor C
Published: March 2020

Introduction

Daily wound care is an important part of burn wound management to help prevent infection. Literature suggests that daily Chlorhexidine Gluconate (CHG) bathing can reduce the risk of acquiring Multi-Drug Resistant Organisms (MDRO). The purpose of this study was to identify change in overall MDRO acquisition in the Burn Unit with the addition of a 1% CHG solution for wound care to the CHG bathing protocol for burn patients.

Methods

Prior to March 2018, routine bathing and wound care involved use of CHG-incompatible antibacterial soap and water followed by 2% chlorhexidine gluconate cloths to intact skin. In March 2018, the bathing protocol changed, in consultation with the hospital’s infection prevention program, to involve a 1% CHG solution for burn wounds followed by 2% CHG cloths to intact skin in order to prevent the loss of protective residual CHG due to rinsing with CHG-incompatible soap and water. A solution of 1% CHG was chosen by staff as an acceptable concentration for wound bathing. Adherence was measured through review of daily documentation of bathing in the electronic medical record. Incidences of burn unit-attributable hospital-onset MDRO cultures were reviewed for the following periods: Baseline (Aug 2016-Aug 2017), Phase-In (Sept 2017 – Aug 2018) and Post-Implementation (Sept 2018 – Aug 2019).

Results

Adherence was >85% throughout the intervention period. No adverse events were noted. Incidences of hospital-onset burn unit MDROs during the following time periods were: 22 cases (Baseline), 15 cases (Phase-In), and 10 cases (Post-Implementation). The most common organisms in the baseline period were Extended-Spectrum b-Lactamase (ESBL) Escherichia coli, MRSA, and Multi Drug Resistant Pseudomonas; and post-implementation, the most common organisms were: MRSA and MDR-Pseudomonas.

Conclusions

A change to a 1% CHG solution for rinsing burn wounds in the setting of 2% CHG cloths to intact skin was well tolerated and associated with a decline in MDRO acquisition attributable to the burn ICU in the one-year post implementation.

Applicability of Research to Practice

The use of a 1% CHG solution for burn wounds may help prevent MDRO acquisition in the highly susceptible and unique burn population.
76 The Effect of Splinting of Metacarpophalangeal Joints After Skin Grafting: A Review of the ACT Database
Authors: Welsh Ashley M , Dewey William S , Casey James C , Cunningham Kyle B
Published: March 2020

Introduction

Hands are the most common area of the body to sustain a burn injury. Maintaining motion and function throughout the healing process of a burn injury is one of the most important goals of the rehabilitation process. After a deep burn to the dorsal aspect of the hand requiring skin grafting, the adjacent metacarpophalangeal (MCP) joints are at risk for developing a burn scar contracture (BSC), limiting the joints’ ability to fully flex towards a fist position. Post-operative positioning protocols state that patient’s hand should be temporarily immobilized for graft protection. A resting hand splint is used to maintain the wrist in approximately 20–30 degrees of extension, MCP joints at approximately 50–70 degrees of flexion and the interphalangeal joints in full extension. The purpose of this study was to assess the benefit of splinting as a treatment intervention to prevent MCP joint extension contractures following dorsal hand skin grafting.

Methods

This was a retrospective review of prospectively collected observational data from the “Burn Patient Acuity Demographics, Scar Contractures and Rehabilitation Treatment Time Related to Patient Outcomes” (ACT) study. Patients were included with grafted dorsal hand burns occurring within 1 of the 4 established cutaneous functional units (CFU) along the dorsal aspect of the second through fifth metacarpals. Since most subjects had more than one dorsal hand CFU involved, the number of CFUs were analyzed as opposed to the number of subjects. Isolated MCP joint flexion measurements were utilized to determine incidence of contracture. Included causes of contracture were scar tissue or other soft tissue limitations. Data were then analyzed by two groups: contracted and non-contracted.

Results

A total of 221 dorsal hand CFUs were included in this study; 119 contracted and 102 non-contracted. There was no statistical significant difference between the average splint wear time between the 2 groups. The average percent of affected CFUs grafted within the contracted group was 92.4% compared to 76.8% in the non-contracted group. In burns to the dorsal hand with less than 99% of the CFU grafted, splinting was effective in preventing 60% of MCP joint extension contractures. When greater than 99% of affected CFU was grafted, splinting was effective in prevention only 36% of contractures.

Conclusions

Splinting can be an effective intervention option in preventing MCP extension contractures when less than 75% of the affected CFU has been grafted; however, its effectiveness decreases as the percentage of CFU involvement increases to greater than or equal to 99%.

Applicability of Research to Practice

Determine most effective post-operative rehabilitations plan following dorsal hand skin grafts.
81 Inhalation Injury Is Associated with Long-term Physical, Satisfaction with Life, and Employment Outcomes: A Longitudinal National Database Study
Authors: Stockly Olivia , Wolfe Audrey E , Carrougher Gretchen J , Stewart Barclay T , Gibran Nicole S , Kowalske Karen J , Schneider Jeffrey C , Ryan Colleen M , Wolf Steven E
Published: March 2020

Introduction

The effects of inhalation injury on mortality are well established. However, little is known about the long-term impacts of inhalation injuries on survivors. This study aims to describe the inhalation injury population and examine differences in long-term physical, mental, employment, and satisfaction with life outcomes between adult burn survivors with and without inhalation injury.

Methods

Data from the Burn Model System National Database (1993–2019) were analyzed. Demographic and clinical characteristics of those with and without inhalation injury were assessed. The Physical Health Composite Scale (PCS) and Mental Health Composite Scale (MCS) of the Short Form-12 Health Survey, Employment Status, and Satisfaction with Life Scale (SWLS) were analyzed at 24 months post-injury. Regression analyses assessed whether inhalation injury was associated with each outcome, which were adjusted for age, gender, race, ethnicity, and burn size.

Results

The analysis included 4,045 individuals (452 with inhalation injury, 3,593 without inhalation injury). Those with inhalation injury had larger burn size, longer hospital lengths of stay, and more operations; they were less likely to be employed at injury and injured at work, and took longer to gain employment after injury (Table 1). Two years after injury, individuals with inhalation injury were half as likely to be working (OR = 0.49, p< 0.001), and had worse PCS (β=-2.51, p=0.021) and SWL scores (β=-2.35, p=0.006) compared to those without inhalation injury. MCS scores did not differ between groups.

Conclusions

Burn survivors with inhalation injuries experience lower rates of employment, worse physical functioning, and worse satisfaction with life outcomes at 24 months post-injury compared to those without inhalation injuries.

Applicability of Research to Practice

Burn survivors with an inhalation injury may require supplementary resources and treatment as well as monitoring of sequelae long-term.