bluuebunny/crossref_metadata_2025 huggingface dataset:
EACVI survey on radiation exposure in interventional echocardiography
Authors: Galli E , Soliman-Aboumarie H , Gargani L , Szymański P , Gimelli A , Petersen S E , Sade L E , Stankovic I , Donal E , Cosyns B , Agricola E , Dweck M R , Ajmone Marsan N , Delgado V , Muraru D
Published: April 2024

Aims

The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey on radiation exposure in interventional echocardiography. The survey aimed to collect data on local practices for radioprotection in interventional echocardiography and to assess the awareness of echocardiography operators about radiation-related risks.

Methods and results

A total of 258 interventional echocardiographers from 52 different countries (48% European) responded to the survey. One hundred twenty-two (47%) participants were women. Two-thirds (76%) of interventional echocardiographers worked in tertiary care/university hospitals. Interventional echocardiography was the main clinical activity for 34% of the survey participants. The median time spent in the cath-lab for the echocardiographic monitoring of structural heart procedures was 10 (5–20) hours/month. Despite this, only 28% of interventional echocardiographers received periodic training and certification in radioprotection and 72% of them did not know their annual radiation dose. The main adopted personal protection devices were lead aprons and thyroid collars (95% and 92% of use, respectively). Dedicated architectural protective shielding was not available for 33% of interventional echocardiographers. Nearly two-thirds of responders thought that the radiation exposure of interventional echocardiographers was higher than that of interventional cardiologists and 72% claimed for an improvement in the radioprotection measures.

Conclusion

Radioprotection measures for interventional echocardiographers are widely variable across centres. Radioprotection devices are often underused by interventional echocardiographers, portending an increased radiation-related risk. International scientific societies working in the field should collaborate to endorse radioprotection training, promote reliable radiation dose assessment, and support the adoption of radioprotection shielding dedicated to interventional echocardiographers.
ST-segment elevation myocardial infarction in Nail–Patella syndrome with anomalous coronary anatomy and aneurysms: a case report
Authors: Varkoly Kyle , Parekh Akarsh , Kaplan Jason , DeYoung Michael Blair
Published: April 2024

Background

Nail–Patella syndrome (NPS) is an autosomal-dominant pleiotropic condition characterized by pelvic and skeletal abnormalities and most commonly affecting a tetrad of nails, knees, elbows, and iliac horns, the iliac horns being pathognomonic for the condition. The most well-documented extra-skeletal manifestation is renal involvement with alteration in Type III collagen. No documented cases of NPS with anomalous coronary arteries or aneurysms, acute coronary occlusion, or successfully coronary interventions exist in the medical literature.

Case summary

A 62-year-old female with a medical history significant for NPS diagnosed 50 years ago presented to the emergency department with a chief complaint of chest pain. She recently developed end-stage renal disease managed with peritoneal dialysis within the last year. Angiography revealed 100% right coronary artery occlusion with an anomalous take-off from the left circumflex artery. She demonstrated diffuse coronary aneurysms in the right coronary artery, mid-left anterior descending artery, and other epicardial vessels. Two drug-eluting stents were placed in overlapping fashion. Following careful apposition, the aneurysmal segment was successfully stented without complication. The patient was discharged without complication 2 days later.

Discussion

Our case shows the first reported case of coronary vascular anomalies and successful coronary revascularization in a patient with NPS in the medical literature. Given the recently reported vascular anomalies and known collagen alterations seen in patients with the genetic disorder, clinicians should suspect further systemic vascular anomalies with their own unique therapeutic challenges when encountering patients with this rare genetic syndrome.
Gigantic biatrial myxoma in a young female with an atrial septal defect: a case report
Authors: Radner Caroline , Grefen Linda , Dashkevich Alexey , Hagl Christian , Mueller Christoph S
Published: April 2024

Background

Myxomas are uncommon and benign cardiac neoplasms that can present with various cardiac, systemic, embolic, or without symptoms depending on their location and size. Very few cases of large, truly biatrial, or tumours connected via the cardiac atria have been reported throughout the years.

Case summary

We present an unusual case of an apparently healthy 25-year-old French woman, who presented with dyspnoea at Munich’s Octoberfest. Echocardiography and computed tomography identified gigantic masses in left and right atrium, which were connected through an atrial septal defect. They were successfully removed by emergent cardiac surgery.

Discussion

This case describes an uncommon tumour and highlights the importance of a quick diagnosis and prompt surgery. We describe the management and surgery for atrial myxomas as well as demonstrating pre- and intraoperative pictures.
A case series of eight amateur athletes: exercise-induced pre-/syncope during the Zurich Marathon 2023
Authors: Hametner Greta , Eis Doris , Kruijver Muriel , Stiefel Michael , van der Stouwe Jan Gerrit , Stüssi-Helbling Melina , Forrer Anja , Niederseer David
Published: April 2024

Background

Marathon running poses unique cardiovascular challenges, sometimes leading to syncopal episodes. We present a case series of athletes who experienced pre-/syncope during the Zurich Marathon 2023, accompanied by elevated cardiac biomarkers.

Case summary

Eight athletes (2 females, 6 males) aged 21–35 years, with pre-/syncope and various additional diverse symptoms such as dizziness and palpitations during the (half-)marathon, were admitted to two emergency departments in Zurich, Switzerland. Clinical evaluations included electrocardiogram, echocardiography, telemetry, coronary computed tomography (CT) scans, and cardiac biomarker assessments. High-sensitive troponin T (hs-cTnT) was elevated in all cases at initial assessment and returned to normal at follow-up. All athletes who received CT scans had normal coronary and brain CT results. None of the eight athletes had underlying cardiovascular disease. Renal function normalized post-admission, and neurological symptoms resolved within hours. Creatinine levels indicated transient acute kidney injury. A common feature was inexperience in running, inadequate race preparation, particularly regarding fluid, electrolyte, and carbohydrate intake, along with pacing issues and lack of coping strategies with heat.

Discussion

From a clinician perspective, the case series highlights the challenge in the management of patients with a pre-/syncopal event during strenuous exercise and elevated cardiac biomarkers. Diverse initial symptoms prompted tailored investigations. Adequate training, medical assessments, and awareness of syncope triggers are essential for marathon participants. Caution and pacing strategies are crucial, especially among novices in competitive running. This information is pertinent given the growing popularity of marathon events and prompts a standardized diagnostic approach after these events.
Repeated occurrence of severe hypotension associated with azithromycin infusion in a patient with fulminant myocarditis: a case report
Authors: Lenz Max , Krychtiuk Konstantin A , Zilberszac Robert , Speidl Walter S , Heinz Gottfried
Published: April 2024

Background

Intravenous administration of azithromycin has been linked to severe hypotension in some case reports in the past. We report a further case of profound shock requiring excessive use of vasopressors and extracorporeal membrane oxygenation (ECMO).

Case summary

An 18-year-old Caucasian male was admitted due to fulminant myocarditis and signs of cardiogenic shock. He had to be put on venoarterial ECMO only hours after admission. Due to the occurrence of disseminated intravascular coagulation and heparin-induced thrombocytopenia, haemodynamic support was discontinued on Day 8. On Day 11 of his stay, the patient started to exhibit signs of severe infection and a single 1500 mg dose of azithromycin was prescribed. Immediately after starting the infusion, the patient developed profound hypotension and signs of cardiogenic shock. Consecutively, venoarterial ECMO had to be re-established, and the azithromycin infusion was stopped in the process. It took the restart of the compound to recognize the connection between the administration of the therapy and the occurrence of cardiogenic shock. After discontinuing azithromycin, no further sudden hypotensive episodes were recorded, and the patient received left ventricular assist device implantation as a bridge to recovery or transplant.

Discussion

Rapid-onset hypotension appears to be a very rare but important adverse drug reaction associated with intravenous administration of azithromycin. Factors such as preceding infection and reduced biventricular function may facilitate the described occurrence.
Spot urinary sodium-guided titration of intravenous diuretic therapy in acute heart failure: a pilot randomized controlled trial
Authors: Khorramshahi Bayat Maryam , Chan Wandy , Hay Karen , McKenzie Scott , Adhikari Polash , Fincher Gavin , Jordan Faye , Ranasinghe Isuru
Published: April 2024

Background

Spot urinary sodium concentration (UNa) is advocated in guidelines to assess diuretic response and titrate dosage in acute heart failure (AHF). However, no randomized controlled trial data exist to support this approach. We performed a prospective pilot trial to investigate the feasibility of this approach.

Methods and results

Sixty patients with AHF (n = 30 in each arm) were randomly assigned to titration of loop diuretics for the first 48 h of admission according to UNa levels (intervention arm) or based on clinical signs and symptoms of congestion (standard care arm). Diuretic insufficiency was defined as UNa <50 mmol/L. Endpoints relating to diuretic efficacy, safety, and AHF outcomes were evaluated. UNa-guided therapy patients experienced less acute kidney injury (20% vs. 50%, P = 0.01) and a tendency towards less hypokalaemia (serum K+ <3.5 mmol, 7% vs. 27%, P = 0.04), with greater weight loss (3.3 kg vs. 2.1 kg, P = 0.01). They reported a greater reduction in the clinical congestion score (−4.7 vs. −2.6, P < 0.01) and were more likely to report marked symptom improvement (40% vs. 13.3%, P = 0.04) at 48 h. There was no difference in the length of hospital stay (median length of stay: 8 days in both groups, P = 0.98), 30-day mortality, or readmission rate.

Conclusion

UNa-guided titration of diuretic therapy in AHF is feasible and safer than titration based on clinical signs and symptoms of congestion, with more effective decongestion at 48 h. Further large-scale trials are needed to determine if the superiority of this approach translates into improved patient outcomes.

Trial registration number

ACTRN12621000950864
Current treatments for the management of homozygous familial hypercholesterolaemia: a systematic review and commentary
Authors: Gu Jing , Gupta Rupal N , Cheng Henry K , Xu Yingxin , Raal Frederick J
Published: April 2024

Aims

Homozygous familial hypercholesterolaemia (HoFH) is a rare disorder characterized by markedly elevated circulating low-density lipoprotein cholesterol (LDL-C) from birth. This review aimed to critically evaluate treatments for HoFH with respect to their efficacy, safety, accessibility, overall context and position within the treatment pathway.

Methods and results

A mixed-methods review was undertaken to systematically identify and characterize primary interventional studies on HoFH, with a focus on LDL-C reduction as the primary outcome. Interventions assessed were ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), lomitapide, evinacumab, with or without LDL apheresis. Twenty-six seminal studies reporting unique patient data were identified. Four studies were randomized controlled trials (RCTs) with the remainder being single-arm trials or observational registries. Data extracted were heterogeneous and not suitable for meta-analyses. Two RCTs, assessed at being low risk of bias, demonstrated PCSK9i were safe and moderately effective. A randomized controlled trial (RCT) demonstrated evinacumab was safe and effective in all HoFH subgroups. Lomitapide was reported to be efficacious in a single-arm trial, but issues with adverse events, tolerability, and adherence were identified. An RCT on ezetimibe showed it was moderately effective when combined with a statin. LDL apheresis was reported as effective, but its evidence base was at very high risk of bias. All interventions lowered LDL-C, but the magnitude of this, and certainty in the supporting evidence, varied.

Conclusion

In practice, multiple treatments are required to treat HoFH. The sequencing of these should be made on an individualized basis, with consideration made to the benefits of each intervention.
Ethnicity and sudden cardiac death in athletes: insights from a large United Kingdom registry
Authors: Finocchiaro Gherardo , Radaelli Davide , D’Errico Stefano , Bhatia Raghav , Papadakis Michael , Behr Elijah R , Westaby Joseph , Sharma Sanjay , Sheppard Mary N
Published: April 2024

Aims

The relationship between ethnicity and causes of sudden cardiac death (SCD) in athletes is poorly understood.

Objectives

To investigate aetiology of SCD among different ethnicities in a large cohort of athletes.

Methods and results

Between 1994 and November 2022, 7880 cases of SCD were consecutively referred from all over the United Kingdom to our national cardiac pathology centre; 848 (11%) were athletes. All cases underwent detailed autopsy evaluation by expert cardiac pathologists. Clinical information was obtained from referring coroners. Most of athletes were white (n = 758; 89%). Black and Asian athletes were in number of 51 (6%) and 39 (5%), respectively. A structurally normal heart, indicative of sudden arrhythmic death syndrome (SADS) was the most common autopsy finding (n = 385; 45%), followed by myocardial diseases (n = 275; 32%), atherosclerotic coronary artery disease (CAD) (n = 58; 7%), and coronary artery anomalies (n = 29; 3%). In most of cases, death occurred during exercise (n = 737; 87%). Arrhythmogenic cardiomyopathy (ACM) was more common in black (n = 13; 25%) than in white (n = 109; 14%) and Asian (n = 3; 8%) athletes (P = 0.03 between black and white athletes; P = 0.04 between black and Asian athletes); in contrast, CAD was more common in Asians (n = 6; 15% vs. n = 51; 7% in whites vs. n = 1; 2%; in blacks, P = 0.02 between Asian and black athletes). Among white athletes, ACM was more common in individuals who died during exercise than in the ones who died at rest (P = 0.005). Such a difference was not observed in Asian and black athletes. In Asian athletes, CAD was the diagnosis at autopsy in 18% of individuals who died during exercise and in none of individuals who died at rest.

Conclusion

A structurally normal heart at autopsy and myocardial diseases are the most common findings in athletes who died suddenly. While ACM is more common in black athletes, atherosclerotic CAD is more common in Asian athletes, with a strong association with exercise-induced SCD. ACM appears to be a driver of exercise-induced SCD in white athletes, however this is not the case in black and Asian athletes.
Hypoxia, hypoxia-inducible factors and inflammatory bowel diseases
Authors: Hou Fei , Bian Xixi , Jing Dehuai , Gao Huikuan , Zhu Fengqin
Published: April 2024

Adequate oxygen supply is essential for maintaining the body's normal physiological function. In chronic inflammatory conditions such as inflammatory bowel disease (IBD), insufficient oxygen reaching the intestine triggers the regulatory system in response to environmental changes. However, the pathogenesis of IBD is still under investigation. Recent research has highlighted the significant role of hypoxia in IBD, particularly the involvement of hypoxia-inducible factors (HIF) and their regulatory mechanisms, making them promising therapeutic targets for IBD. This review will delve into the role of hypoxia, HIF, and the associated hypoxia-inflammatory microenvironment in the context of IBD. Potential interventions for addressing these challenging gastrointestinal inflammatory diseases will also be discussed within this framework.
Convalescent Growth Differentiation Factor-15 and Long-Term Outcomes after an Acute Coronary Syndrome
Authors: Greer Charlotte E , Chew-Harris Janice , Adamson Philip D , Pemberton Chris J , Pickering John W , Pilbrow Anna P , Frampton Chris M , Troughton Richard W , Doughty Robert N , Richards A Mark
Published: April 2024

Background

Growth differentiation factor-15 (GDF-15) has been shown to be associated with adverse clinical outcomes in patients after an acute coronary syndrome when measured soon after an event. Although dynamic in the acute phase after myocardial injury, GDF-15 has been shown to remain stable during convalescence. In this study, we aimed to assess the value of GDF-15 as a long-term prognostic marker for clinical outcomes when measured in the convalescent phase following an acute coronary syndrome.

Methods

GDF-15 concentrations were measured in 1945 patients who were recruited between 2002 and 2009 to the Coronary Disease Cohort Study. For this analysis, follow-up was curtailed at 10 years and association of GDF-15 with all-cause death, cardiovascular death, recurrent myocardial infarction, and heart failure hospitalizations were assessed with multivariate Cox proportional hazard regression analysis.

Results

After 10 years of follow-up, there were 648 deaths (348 from cardiovascular causes), 500 admissions for myocardial infarction, and 436 for heart failure. Four-month convalescent GDF-15 demonstrated a robust independent association with all endpoints, which remained after adjustment for Global Registry of Acute Coronary Events score and other convalescent biomarkers. When compared to the lowest quartile of GDF-15 concentrations, those in the highest quartile had a 3-fold increased risk of all-cause death.

Conclusions

Convalescent plasma GDF-15 is a strong and independent predictor of 10-year all-cause death, cardiovascular death, recurrent myocardial infarction, and heart failure admission following an acute coronary syndrome.

Australian New Zealand Clinical Trials Registry Trial ID

ACTRN12605000431628.
1 Burn Center Verification and Safety-net Status. Are There Differences in Discharge to Inpatient Rehabilitation?
Authors: Lakhlani Devi , Bailey John Kevin , Steeman Samantha , Stanton Eloise , Sheckter Clifford C
Published: April 2024

Introduction

Discharge to acute rehabilitation is the gold standard following major burn injury. However, numerous barriers to rehabilitation exist, including race, payor type, and burn center type. It remains unclear whether the organizational structure of burn centers is associated with differences in discharge to rehabilitation. This study aims to investigate associations between race and burn center type in relation to the rate of discharge to acute rehabilitation.

Methods

Using the California Health Care Access and Information from 2009-2019, all inpatient encounters at verified and non-verified burn centers were identified using International Classification of Diseases 9/10 and Diagnosis Related Group codes. The primary outcome of interest was proportion of patients discharged to acute rehabilitation. Key covariates included race, burn center safety-net status, American Burn Association (ABA) verification status, and American College Surgeons (ACS) Level 1 trauma center designation. Adjusted covariates included burn total body surface area (TBSA), gender, and age. Logistic regression modeling was performed, and multiple testing was accounted for using Bonferroni adjustment.

Results

There were 27,496 encounters of which 0.8% (228) were discharged to inpatient rehabilitation. By race/ethnicity, the proportion of admission to inpatient rehabilitation was 0.9% for White, 0.6% for Black, 0.7% for Hispanic, and 1% for Asian. After adjusting for TBSA and age, notable predictors for discharge to inpatient rehabilitation included Medi-Cal (Medicaid) as payor (OR 1.24-2.22, p=0.005) compared to commercial insurance, trauma center status (OR 1.37-3.16, p=0.005), ABA verification status (OR 1.16-2.69, p=0.040), and safety-net facility (OR1.12-2.01, p=0.030). On univariate testing Black race and Hispanic ethnicity were associated with decreased odds of discharge to inpatient rehabilitation (p=0.033). This relationship was erased when these patients were treated at verified burn centers and/or burn centers with safety-net status.

Conclusions

Discharge to inpatient rehabilitation remains variable between burn centers and races. Notably, verified burn centers with safety-net designation had more patients that discharged to inpatient rehabilitation adjusting for burn severity and payor. Governmental insurance was favorable for discharge to acute rehabilitation.

Applicability of Research to Practice

The organization of burn centers and triage of burn patients may consider the benefits of verification and safety-net designation as it relates to discharge to inpatient rehabilitation.
30 A Qualitative Descriptive Exploration of the Experiences of Burn Therapists
Authors: Yelvington Miranda L , Wood Rachel E , Corson Tyler , Hu Jiale , Reynolds Stacey
Published: April 2024

Introduction

Exposure to patients who have experienced major traumatic events places burn therapists at risk for developing high levels of anxiety and stress, directly impacting their quality of life. Poor professional quality of life has been associated with negative physical and emotional characteristics in healthcare professionals and can subsequently influence patient safety and satisfaction, job retention, and productivity. The purpose of this study was to understand and describe the experiences of occupational and physical therapists who provide acute therapy to people who have sustained burn injuries.

Methods

The study utilized a qualitative descriptive approach. Participants were selected using a maximum variation sampling strategy. Years of burn experience ranged from 2 to 37 years, and participants practiced in adult (40%), pediatric (20%), or mixed burn care (40%). Participating therapists represented all five American Burn Association Regions. Semi-structured interviews were completed with 10 participants (8 female, 7 physical therapists) to explore their experiences in their own words. Conventional content analysis was used to analyze the data collected from semi-structured interviews.

Results

Six themes emerged after content analysis. These themes were: 1) the importance of therapeutic relationships to patient successes and therapists’ retention; 2) the autonomy and flexibility of burn therapists; 3) the impact of career longevity on compassion; 4) the uniqueness of burn team relationships and camaraderie; 5) the challenges of operating within the business of a healthcare system; and 6) the physical, mental and emotional challenges to the burn therapists’ resiliency.

Conclusions

The overarching themes reflected the importance of therapeutic relationships to patient successes and therapists’ retention. The autonomy and flexibility of burn therapists were found to be a driver of professional quality of life as therapists were empowered by their ability to lead patient change. Therapists endorsed developing boundaries and methods to decrease the emotional impact of patient losses as their career progresses. Participants spoke about the positive and negative impact of being part of a multidisciplinary team, often feeling limited by the challenges inherent in operating within the business of a healthcare system.

Applicability of Research to Practice

This research brings to light the physical, mental, and emotional challenges that impact burn therapists’ resiliency and which should be considered when creating programs to increase retention and professional quality of life in this population.
32 HANDFULS: A New Clinically Feasible Measure of Hand Outcome for Children with Burns and Trauma
Authors: Parry Ingrid , James Michelle , Wilson Machelle , Greenhalgh David G
Published: April 2024

Introduction

Fine motor dexterity is important for children's normal hand function and development. In-hand manipulation (the collection and repositioning of items in the hand) and palmar workspace (functional volume in the palm) are two aspects of hand function that often become simultaneously impaired after hand trauma or burn injury. Rehabilitation emphasizes recovery of these hand functions yet few functional outcome measures address both of these constructs and even fewer are appropriate for children.

Methods

This study developed a new hand outcome measure to specifically assess these constructs and tested it on 192 children between the ages of 2-21. The test, called ‘HANDFULs’, uses simple instructions and inexpensive materials (i.e. marbles) shown in Figure 1. Means, standard deviations, and 95% confidence limits were estimated for children in seven age groups. Associations between age and the HANDFULs variables were examined using one-factor ANOVA. Multiple regressions were fit to test for associations between age and the HANDFULs variables after controlling for height, hand size, and hand strength. A stepwise selection procedure was then implemented, holding age into the model, to remove otherwise non-significant variables. Test-retest reliability was tested with the Shrout Fleiss Reliability Index and significance was set at p< 0.05.

Results

Expected normal values are reported in Figure 2 for palmar workspace volume (marbles that fit in the hand) and in-hand manipulation (collection time per marble) by age group. Age (0.16 (0.06), p=0.009), hand span (0.47 (0.09), p< 0.0001) and hand width (0.9 (0.29), p=0.003) were significantly associated with number of marbles that fit in the hand, representing palmar workspace capacity. Although hand strength and size characteristics were tested, only age (-0.02 (0.01), p=0.001) was significantly associated with the HANDFULs score of time per marble. The Intraclass Correlation Coefficient was 0.94 demonstrating excellent test-retest reliability.

Conclusions

This study developed a new pediatric hand outcome measure to address hand function to address a gap related to burn and trauma recovery. The measure was tested on able-bodied, noninjured children to establish validity and reliability, provide reference values for patients with injuries by age groups, and is clinically feasible to administer.

Applicability of Research to Practice

Outcome test for burn injured hands.
34 The Costs of Caring: Quantifying Compassion Fatigue and Compassion Satisfaction in Burn Therapists
Authors: Yelvington Miranda L , Corson Tyler , Hu Jiale , Wood Rachel E , Reynolds Stacey
Published: April 2024

Introduction

Recovery from a severe burn injury requires early and aggressive therapy, which is often painful and distressing to the patient. Burn therapists who guide these interventions may be prone to experiencing secondary trauma and compassion fatigue through repeated exposure to difficult situations. At the same time, therapists may gain a sense of purpose and altruism from their work, fostering compassion satisfaction. Despite being well documented in other health professions, compassion fatigue and compassion satisfaction have not been sufficiently explored among burn therapists. The purpose of this study was to quantify and characterize burn therapist’s compassion fatigue and satisfaction using the Professional Quality of Life (ProQOL) scale and to answer the question of what job-related factors may impact these outcomes.

Methods

This cross-sectional study surveyed active burn therapists using Research Electronic Data Capture (REDCap). ProQOL scores were calculated for individual respondents and described for the sample using mean, standard deviation, and range. Multiple regression analyses were conducted to assess the impact of predictor variables of years in burn care, practice setting, and population on the subscales of the ProQOL for compassion satisfaction and compassion fatigue (burnout and secondary traumatic stress).

Results

A total of 143 burn therapists were included, which exceeded the n needed to achieve statistical power. The included participants presented with low to moderate burnout scores (mean=23.5, range=11-38), secondary traumatic stress (22.5, 11-40), and moderate to high compassion satisfaction (40.4, 25-50). Regression analyses found years of practice significantly predicted (p ≤ .01) each of the compassion constructs.

Conclusions

This study presents new knowledge for the field of burn care in its quantification of professional quality of life in burn therapists. While burn therapists experience moderate-to-high levels of compassion satisfaction in their work, burnout and stress also approached moderate levels. Years of practice was a significant predictor of compassion and may be related to increased competence or confidence in practice.

Applicability of Research to Practice

This study is the first to study compassion fatigue and satisfaction in burn therapists. Understanding and addressing these issues are essential to recruiting and retaining a healthy and productive burn care workforce. Regular assessment of professional quality of life and career stage-specific supportive measures could provide a protective measure against compassion fatigue.
60 Safety of Maintaining Nutrition Through Moderate Sedation for Burn Wound Care
Authors: Kohler Amber D , Donnelly Melanie , Balstad Blaire , Mueller Scott W , Patton Lacey , Gibson Cameron , Wiktor Arek J
Published: April 2024

Introduction

Physiologic changes in burn patients create a hypermetabolic state increasing nutrition requirements. The American Society of Anesthesiology recommends patients be made NPO with enough time to allow for gastric emptying prior to procedural sedation. Daily burn wound care needs requiring sedation make this approach untenable. We aimed to assess the risk of moderate sedation in those without interrupted nutrition.

Methods

A 12-month single centered retrospective analysis at our ABA verified center was performed. Burn patients with natural airways (non-intubated/non-trached) receiving moderate sedation for wound care with a Richmond Agitation-Sedation Score (RASS) goal of -3 were included. Timing of nutritional intake prior to the start of procedural sedation, total amount of drugs administered, lowest RASS score, and all adverse events throughout procedural sedations, including aspiration/pneumonia were recorded. Confidence intervals (CI) were calculated to estimate the risk of adverse events in this cohort.

Results

A total of 97 moderate sedations were completed on 24 patients (66.7% male) with a mean age 43 years (range 18-79), mean total TBSA 13.3% (range 4.5-38.5), and mean ASA score 1.9 (range 1-3). Patients averaged 2.9 oral premedication agents (opiate 100%, lorazepam 92%, ketamine 75%, dexmedetomidine 18%) and 2.75 IV agents administered, with mean doses of fentanyl 148mcg, midazolam 2mg, ketamine 50mg, and maximum dexmedetomidine infusion of 0.85 mcg/kg/hr. Patients achieved a mean RASS of -1.9 (range 0 to -4). On average, nutrition of any kind was consumed 109 minutes prior to sedations, with an average of 171 minutes from consumption of solids. In 24 sedations (24%), 6 patients had tube feeds continued throughout wound care. Location of feeding tubes during sedations: 21 gastric, 3 post-pyloric. One episode of nausea occurred after premedications were given (95% CI 0.03-5.6%). Ondansetron was given to the patient prior to the start of the moderate sedation without further nausea/complications. No complications related to aspiration were noted in any sedation event (97.5% upper CI 3.7%), including no episodes of vomiting, evidence of aspiration, pneumonia, hypoxia, complete airway obstruction, laryngospasm, or death. Hypertension was noted in 17 sedations, treated in 1 event. Hypotension was noted in 6 sedations, each requiring a decrease in the IV dexmedetomidine infusion.

Conclusions

No harmful adverse events were associated with maintained nutrition throughout the peri- and intra-sedative wound care periods, despite ongoing gastric tube feeds in this small sample of burn patients. A large prospective study is required to further validate this practice.

Applicability of Research to Practice

Institutions should consider ongoing nutrition requirements and apply risk-benefit conversations when adopting a burn specific sedation policy.
61 The Influence of Sarcopenia on Patient Outcomes Among Burn Patients: A National Burn Repository Study
Authors: Blears Elizabeth , Ballou Jessica , Murton Andrew , Caffrey Julie A
Published: April 2024

Introduction

Over recent decades, improvements in triage and hospital protocols have resulted in remarkable increases in survival following major burns. Despite this, patients continue to experience profound muscle cachexia, in large part, a consequence of the hypermetabolic response to burn injury. However, the rates of cachexia among burn and adult patients are not well established across multiple burn centers.

Methods

The National Burn Repository (NBR) was used to explore the rate of sarcopenia and associated characteristics of patients diagnosed with sarcopenia while undergoing burn treatment in both the acute and follow-up setting. Diagnoses of sarcopenia was made according to appropriate ICD-9 and ICD-10 codes. Appropriate descriptive statistics were used to characterize the burden of muscle wasting and sarcopenia among burn patients with alpha < 0.05 as significant. Binomial and linear multivariate regression was performed to determine whether sarcopenia was an independent predictor of adverse burn outcomes after adjusting for common confounding variables, such as age, burn size and comorbidities.

Results

In total, the NBR provided 84,438 adult and pediatric burn patients injured between 2000-2018 from over 100 burn centers predominantly in the United States. Only 2.5% (N=2,118) of the patients in the NBR were diagnosed with having sarcopenia or other forms of muscle atrophy. Patients with sarcopenia were significantly older (: 51.9 years (SD±21) vs 35.5 years (SD±23.6), P< 0.001), larger Total Body Surface Area burn (mean: 16.1% (SD±19.2) vs 7.1% (SD±11.5), P< 0.001) and required more surgical procedures (mean: 21.9 total procedures (SD±30.4) vs 7.9 total procedures (SD±13.7), P< 0.001). After adjusting for confounding variables, sarcopenia remained an independent predictor of ability to discharge to independent living (vs nursing facility or home with home nursing), longer inpatient days as well as increased number of surgical procedures (P < 0.001).

Conclusions

Sarcopenia is an independent risk factor for adverse outcomes in burn patients, such as decreased likelihood of discharge to independent living, increased length of stay inpatient and increased number of surgical procedures. Confidence in these findings would be improved with more accurate data collection, as the diagnosis of sarcopenia is likely under-reported, under-diagnosed or both.

Applicability of Research to Practice

Understanding the role of sarcopenia in clinical outcomes can better optimize nutrition and exercise service that can lead to better long-term outcomes.
62 Cognitive Behavioral Therapy Improves Symptoms of Depression in Burn Survivors
Authors: Rothbauer Mikki J , Pasek Zuzanna , Wewerka Sandi S , Dalrymple Kirsten A , Adams Nell
Published: April 2024

Introduction

Burn injury patients can suffer severe trauma as they cope with the events that led to their injuries and their new physical abilities and appearance. Mental health is a component of care that is often overlooked for these patients. The purpose of this prospective study was to evaluate whether burn psychotherapy is effective in reducing depression in burn survivors.

Methods

Our Burn Center has a full time licensed clinical psychotherapist who uses Cognitive Behavioral Therapy (CBT) to treat patients. Burn clinic nurses administered the Patient Health Questionnaire-9 (PHQ-9) depression screener to n=1842 patients between 2016-2019. Patients were referred to psychotherapy if their total PHQ-9 score met the definition for moderate depression (total score ≥ 10) or they endorsed the question about suicidal thoughts. Patients could also participate through self-referral.

Our final sample included n=146 patients (47% female, mean age=41.8) who attended at least one psychotherapy appointment and contributed at least one post-appointment PHQ-9 score. We computed a difference score for each patient by subtracting their baseline PHQ-9 score from their mean post-psychotherapy score. We used a one sample t-test to compare the mean difference score for the group to zero (zero = no change). We also examined how many participants showed a change in PHQ-9 category from pre- to post-psychotherapy.

Results

The mean baseline score was 11.49 (SD = 6.92) vs. mean post-psychotherapy score 8.54 (SD = 6.45). The mean group difference score was significantly different from zero (mean = -2.95, SD=5.72), t(145)=-6.23, p< 0.001, [95% CI = -3.88 to -2.01]. The negative mean difference indicates a decrease in depressive symptoms. When examining changes in depression category, 50.7% of patients moved to a less severe category of depression after psychotherapy, 13.7% of patients moved to a more severe category, and 35.6% did not change.

Conclusions

These results support psychotherapy as a measurable benefit to some, but not all individuals undergoing specialized burn care. Burn centers should consider having a full-time burn- and trauma-trained psychotherapist on staff to complete assessments on admission. Continuity of mental health care in burn centers has the potential to positively influence patient outcomes.

Applicability of Research to Practice

Cognitive behavioral therapy is used in many different populations. Our findings support the practice of specialized psychotherapy intervention in the burn population as effective in decreasing symptoms of depression in some patients.
118 Retrospective Analysis of Pathogens for Guided Creation of an EMPIRic Antibiotic PrEscribing Pathway (EMPIRE)
Authors: Todor Lorraine A , Hill David M
Published: April 2024

Introduction

Mortality from infection due to P. aeruginosa is remarkably high; therefore empiric regimens include its coverage. In a prior study, we showed manual inclusion of bedside prescribing considerations heavily reduced antibiogram-based, empiric recommendations (i.e, double Gram-negative [GN] coverage to a single agent + vancomycin [VAN]). The purpose of this study is to determine if empiric regimens in the burn unit may be optimized further per suspected infection source. We hypothesized an initial regimen of VAN and cefepime (C4) will still adequately cover 90% of definitive pathogens isolated within one week of admission in absence of healthcare-associated infection risk factors (HAIRF). For suspected pneumonia, a narrower beta-lactam can be used with adequate coverage. Lastly, difficult to treat pathogens (DTp) are rarely the cause of wound infection within one week of admission.

Methods

This single-center, retrospective study included patients admitted to the burn unit between January 1, 2020 and December 31, 2022. Patients were screened by reviewing microbiology reports during the study period and exclusion criteria applied to generate a final sample of patients and cultures. Only treated infections were considered (i.e., not surveillance data). A 3-year sample was utilized to ideally achieve 30 isolates of the most common pathogens. Demographic data was reported using descriptive statistics. Sensitivities were reported via antibiotic*pathogen and cumulatively according to source and hypothetical future regimen.

Results

The final sample included 268 pathogens. Tissue samples from wounds, respiratory samples, and blood accounted for 183 (68%) 35 (13%), and 30 (11%) culture sources, respectively. Urine and bone samples made up less than 8% of pathogens. VAN and C4 covered 98% and 90% of Gram-positive and GN pathogens, respectively, within the first week of admission and in absence of HAIRF. Fifteen respiratory cultures grew GN pathogens, of which 83% were susceptible to C4. When used in combination with VAN, 93% of all respiratory pathogens that grew were covered. Narrower beta-lactams, ampicillin-sulbactam or ceftriaxone, plus VAN covered 83% of respiratory pathogens. Of the 183 wound cultures collected, 10 (5.5%) DTp were isolated.

Conclusions

Despite recommendations for empiric double coverage of GNs per the local unit-specific antibiogram, initial use of VAN and C4 remains adequate for pathogens isolated within one week of admission in patients without HAIRF. For pneumonias, a narrower spectrum beta-lactam would not sufficiently cover respiratory pathogens isolated within the first week of admission. DTp are rarely isolated from wound cultures within one week of admission.

Applicability of Research to Practice

Antibiotics must be used judiciously to combat antibiotic resistance. We describe a method to consider for creating empiric prescribing pathways for adequate pathogen coverage while preserving broader agents.
120 Venous Thromboembolism Prophylaxis in Burn Patients
Authors: Stanton Eloise , Yenikomshian Haig A , Gillenwater Justin
Published: April 2024

Introduction

Venous thromboembolism (VTE) is extensively studied in trauma patients, but burn patients require special consideration due to their unique pathophysiology and management strategies. Currently, there are no specific prophylaxis recommendations to help mitigate VTE in burn patients.

Methods

The US National Trauma Data Bank (NTDB) was analyzed to identify patients with burn encounters from 2017-2021 using ICD-10 event codes. Our primary outcome measure was incidence of VTE, which included deep venous thrombosis and pulmonary embolism. Secondary outcome measures included need for blood transfusion and need to return to the operating room due to hemorrhage from skin/soft tissues/extremities. Multivariable regressions were conducted to evaluate the relationship between various VTE prophylaxis types and timing of VTE prophylaxis and VTE incidence while controlling for age, sex, %TBSA and inhalation injury.

Results

A total of 326,614 patients with burn injuries were identified in the NTDB during the study period, of whom 5,604 (1.7%) had a VTE event during their hospital admission. The majority of patients did not receive VTE prophylaxis (54.1%). Of those that did, the most commonly used VTE prophylaxis was LMWH (37.9%), followed by unfractionated heparin (4.1%). When controlling for age, sex, inhalation injury, and %TBSA, unfractionated heparin and LMWH were significantly associated with an increased risk of VTE (heparin: OR=1.8 95% CI 1.3-2.5, p < .001; LMWH: OR=1.5 95% CI 1.2-1.8, p < .001). Longer time to VTE prophylaxis was significantly associated with increased odds of VTE when controlling for the same covariates (OR=1.04 95% CI 1.03=1.07, p < .001). Neither VTE prophylaxis type nor timing of VTE prophylaxis administration was significantly associated with an increased need for blood transfusion. Heparin was the only VTE prophylaxis type significantly associated with increased odds of returning to the OR for a bleeding-related complication (p < .001).

Conclusions

A majority of burn patients in the NTDB did not receive VTE chemoprophylaxis, and counterintuitively, patients who received VTE chemoprophylaxis had higher rates of VTE than patients who did not, despite controlling for known VTE risk factors. In patients who did get chemoprophylaxis, unfractionated heparin is associated with a higher rate of VTE and surgical bleeding complications when compared with LMWH. Delayed initiation of VTE prophylaxis correlates with a higher likelihood of VTE occurrence. These findings underscore the importance of better studying and developing specialized VTE prevention guidelines for burn patients to enhance their care and outcomes.

Applicability of Research to Practice

Prompt initiation of VTE prophylaxis is essential to reduce the risk of VTE among burn patients, highlighting the importance of timely interventions. Developing specialized VTE prevention guidelines for this population can enhance their care and outcomes.
122 Itchy Burns: Debilitating Effects of Pruritus on Daily Activity in Burn Follow-Up Care
Authors: Shrader Elizabeth A , Rathjen Esther A , Eischeid Alexander C
Published: April 2024

Introduction

Current practices in the long term treatment of burn wounds often ignore or only minimally respond to prolonged pruritus, or itching. In truth, the presence of pruritus in patients receiving follow-up care which negatively impacts patient lifestyles is likely under documented and not effectively treated. Quantifying and treating pruritus in a similar fashion to pain management is thus the next logical progression of burn care in an outpatient setting. In this study, we hypothesize that the presence of pruritus positively correlates to daily activity disability and warrants investigation into further intervention.

Methods

All patients presenting for an outpatient appointment for treatment of burn injuries at a regional burn center were provided a 5-D Pruritus Scale questionnaire at the time of their arrival with other clinic paperwork prior to being seen by a provider. Interpreter services for non-English speaking patients and writing assistance for patients with hand injuries were provided, when necessary. The survey collected patient ratings on pruritus duration, degree, direction, disability, and distribution. Responses were de-identified and recorded in numerical form. Of the 127 submitted surveys, blank responses (n=13) and responses which struck/altered the word “itch” and replaced it with “pain” (n=2) were omitted.

Results

Surveys were collected for a 6 week period with a total of 112 valid responses obtained. Of the valid surveys, 44 (39%) reported moderate (level 3/5) itching or higher with 47 patients (41%) indicating at least occasional sleep disruption/challenges resulting from pruritus. Under daily activity disability categories (leisure/social, housework/errands, and work/school), 44 (39%) reported at least occasional inability to complete at least one of the activities with 39 (35%) and 29 (26%) indicating at least occasional disability in two or three of the activities, respectively. It was determined patients reporting moderate pruritus were significantly more likely (p < 0.001) than patients only reporting minimal or mild pruritus to report daily activity disabilities (61% versus 25%, respectively) and sleep disruptions (68% versus 25%, respectively).

Conclusions

This study revealed a higher than expected proportion of patients reporting pruritus leading to daily activity disability during follow-up care for burn injuries. Further, there exists a correlation of patients indicating moderate or worse pruritus with sleep and activity disruptions.

Applicability of Research to Practice

The relationship between increased rates of daily activity disability and degree of pruritus indicates providers should be vigilant in screening for pruritus-related disability and supports trialing additional itch management such as oral and topical medications.