bluuebunny/crossref_metadata_2025 huggingface dataset:
52 Thermal Fuse Mandate Is Cost-effective for Home-oxygen Users in Prevention of Morbidity/mortality and Property Loss
Authors: Sheckter Clifford C , Coffey Rebecca
Published: April 2024

Introduction

Smoking tobacco products while using home oxygen can lead to fires and explosions which cause cutaneous burns, death, and loss of property. Thermal fuses interrupt the propagation of ignited oxygen-lines and significantly reduce the risk of explosion and death. Mandating thermal fuses for all home oxygen users is costly due to the number of people affected and distribution of these resources. On the other hand, the cost of burn care and property loss may exceed the summed device cost. Prior to mandating thermal fuses for all home oxygen users in the US, cost-effectiveness analysis should be performed.

Methods

A Markov model with annual cycling was constructed for the entire US population currently using home oxygen for chronic obstructive pulmonary disease (COPD). The probability of burn, death, and property loss were derived from a systematic review of literature. Societal and Medicare perspectives were adopted evaluating the costs of a federal policy including purchasing and shipping thermal fuses to all home oxygen users. Additional costs included the healthcare required to treat burn patients and the cost of prolonging these lives in advanced COPD. Cost savings included the avoided property loss in 2023 US dollars. Effectiveness was measured in gains in quality adjusted life years (QALYS) based on utilities derived from burn survivors and persons living with COPD. Deterministic and probabilistic sensitivity (10,000 Monte Carlo simulations) analysis was performed for key parameters including the cost of thermal fuses, mortality reduction from thermal fuses, and number of home oxygen fires per year. Discounting was 3% per year.

Results

In the status quo, the 10-year societal cost was $28.67 billion compared to $28.36 billion in the policy mandate (saving $305.40 million at ten years). 1,812 QALYs were gained with the policy mandate, yielding and ICER of -$160,317. For the Medicare payor perspective, the incremental cost-effectiveness ratio (ICER) was $64,981. Deterministic and probabilistic sensitivity analyses showed little variation in the ICER under multiple scenarios. The discrepancy between the dominant ICER for societal perspective and cost-effective ICER for Medicare perspective reflected savings from averted property loss not realized by Medicare.

Conclusions

A national policy mandating and paying for thermal fuses for all home oxygen users is dominant from a societal perspective and cost-effective from a Medicare perspective. The US federal government should adopt such a policy.

Applicability of Research to Practice

This rigorous model demonstrates overwhelming support for a policy that mandates thermal fuses for home oxygen users including direct shipping the device to individuals. Federal and state governments should adopt this policy.
80 Donor Skin Reduction in Full-thickness Wounds Using Autologous Cell Harvesting Device with Meshed Autograft
Authors: Shupp Jeffrey W , Rae Lisa , Bell Derek , Chin Theresa L , Cordova Alfredo C , Foster Kevin N , Castanon Lourdes
Published: April 2024

Introduction

The Autologous Cell Harvesting Device is a medical device designed for regenerative medicine applications. Its primary function is to enable clinicians to prepare an autologous skin cell suspension (ASCS) from a small sample of a patient's skin at the point of care. This innovative approach allows for the use of a patient's own skin cells in various medical procedures. The ASCS device received Food and Drug Administration (FDA) approval in September 2018 for the treatment of acute thermal burn wounds, demonstrating ASCS as an effective tool for promoting tissue regeneration and wound healing while significantly reducing donor skin requirements. This study was designed to evaluate safety and effectiveness of ASCS in conjunction with widely meshed autografts in patients undergoing reconstruction of full-thickness, non-thermal skin defects such as those resulting from trauma and surgery.

Methods

This prospective, randomized, within-subject study enrolled patients ≥5 years of age with acute non-thermal full-thickness skin wounds requiring autografting. Investigators were responsible for their respective autografting plans for closure in alignment with their stand of care. Comparable treatment areas of >80 cm2 each were randomized to receive autografting treatment per investigator’s pre-identified plan (Control), or ASCS treatment in combination with a more widely meshed autograft than that of the Control. Co-primary effectiveness endpoints included 100% healing at (or prior to) 8 weeks post-treatment confirmed at 2 consecutive study visits at least 2 weeks apart, and the ratio of donor site to treatment area expansion ratios.

Results

Of the 65 patients enrolled, 63% (n = 41) had surgical skin defects while 37% (n = 24) had traumatic skin defects. Week 8 healing of the ASCS-treated areas (65%) was non-inferior to the Control areas (58%) (p < 0.025) and donor skin sparing in the ASCS-treated was superior to the Control area, using 27% less donor skin, on average (p < 0.025), meeting both co-primary endpoints.

Conclusions

ASCS application combined with a widely meshed autograft for the treatment of non-thermal full-thickness wounds required significantly less donor skin for closure and had comparable healing outcomes when compared to standard of care. The Autologous Cell Harvesting Device demonstrated its effectiveness in soft tissue wound repair by reducing the amount of donor skin and maintaining consistent healing outcomes.

Applicability of Research to Practice

The Autologous Cell Harvesting Device offers a clinically advantageous approach to autografting by reducing the amount of skin needed for closure without compromise to healing outcomes.
502 Long-term Renal Recovery in Burn-related Acute Kidney Injury Requiring Continuous Renal Replacement Therapy
Authors: Gordon Travis D , Papp Anthony , Al-Zeer Bader
Published: April 2024

Introduction

Acute Kidney injury (AKI) is a common complication of severe burn injury associated with significant morbidity and mortality. Continuous Renal Replacement Therapy (CRRT) is the modality of choice int he treatment of burn-related AKI. The purpose of this study was to look at long-term renal function of burn survivors who required CRRT during their acute stay in ICU as a result of burn-related AKI.

The hypothesis of this study is burn patients who develop burn-related AKI requiring supplemental CRRT during their hospitalization, have return or normal/baseline renal function long-term.

Methods

A retrospective cohort study looking at burn patients at a single institution. Inclusion criteria includes: Adult (> 18yo) burn patients with KDIGO stage 1-3 AKI subsequent to burn injury who received CRRT during ICU admission. Exclusion criteria included preceding chronic kidney disease, kidney transplant. Retrospective data was collected between January 2012 - December 2021 using the institutions Burn registry, and ICU and Renal databases. Renal follow-up was collected up to 3 years post discharge. Statistical analyses was done using Microsoft Excel including T-tests, and multivariate analyses.

Results

Of the 31 patients who met inclusion criteria, 22 survived their burn injuries, a mortality rate of 31.8%. There were no significant differences in demographics, comorbidities, burn characteristics, or critical care interventions between patients who survived vs. those who perished. Serum creatinine values and eGFR values on average normalized to patient baseline at discharge and remained stable through follow up for 91% of patients. 4/22 patients required dialysis after their discharge from hospital (18.2%), 3 within the first year of discharge, but none required dialysis > 3 years after discharge. 5 patients died within 3 years from discharge, 4 of whom died within the first year.

Conclusions

AKI in the setting of severe burn injury is common, often necessitating the need for CRRT. Despite high rates of conversion to chronic kidney disease in the General ICU cohort who develop AKI necessitating CRRT, burn-related AKI requiring CRRT results in much lower rates of conversion to ongoing renal dysfunction. Our cohort showed a return of baseline renal function in 20/22 patients who survived their burn injury (91%) in long-term (> 3years) follow-up. Mortality rates in our cohort were also lower than previously cited literature.

Applicability of Research to Practice

Within our cohort, 91% of our patients had return to baseline renal function after their burn-related AKI, and a mortality rate of 31.8% which is lower than previously cited studies. Given all survivors received CRRT, this could highlight the potential benefit CRRT offers to burn patients in the long-term. Secondly we reported unsatisfactory low rates of long-term renal function follow-up data for burn related AKI, thus highlighting room for improvements in practice.
518 A Review of the Metabolic Consequences of Illicit Simulant Use in Burn Patients
Authors: Ferrari Louis , Taylor Billy Jay , Krueger, Jr. Thomas J , Buchanan Dylon , Bay Curt C , Osborn Suzanne C , Islas Claudia , Whetten Erica , Talanki Nisha , Richey Karen J , Foster Kevin N
Published: April 2024

Introduction

Over the past several decades illicit stimulant (STIM) use has developed into a major, national crisis. At our urban, safety net hospital, this is evident in a consistent increase in patients with chemical evidence of methamphetamine, amphetamine and cocaine use. Adverse health consequences of STIM use are well known, however potential metabolic consequences in patients with significant burns has not been studied. Our hypothesis was that this patient population is both undernourished and hypermetabolic when compared to those who test negative for stimulants.

Methods

This was a retrospective chart review of burn patients over a 6-year period who suffered a burn injury ≥ 20% TBSA and had both toxicology and indirect calorimetry testing completed. Patients were stratified into 2 groups according to toxicology results, positive for stimulants and negative for stimulants. Descriptive statistics were calculated for demographic and outcome data.

Results

A total of 332 patients were admitted over the 6-year period with burn injuries of ≥ 20% TBSA. Among those 140 had both toxicology and indirect calorimetry testing completed. When stratified by toxicology results 34 were positive (POS) and 106 were negative (NEG). There was no significant difference between groups for age 43.21 years POS vs 47.26 years NEG, % TBSA 34% POS vs 35% NEG, or BMI 27.5 kg POS vs 29 kg NEG. Likewise, there were no significant differences in RQ, 0.94 POS vs 0.93, REE 2513 POS vs 2412 NEG or COVAR 5.87 POS vs 5.54 NEG. There was no significant difference in mortality between the two groups 12% POS vs 23% NEG (p=.220).

Conclusions

We were unable to reject the null hypothesis in this study. Nearly two thirds of patients admitted during the study period did not have toxicology testing done and this may have prospectively introduced a selection bias into our retrospective study. Uniformity and protocolization of toxicology testing are necessary to avoid selection bias in order to meaningfully study the potential effects of illicit drugs on the outcomes of burn patients.

Applicability of Research to Practice

While we were unable to demonstrate a significant impact of stimulant use on patient metabolism and nutritional status with this study, it remains our hypothesis that such a relationship exists.
542 Comparative Analysis of Unhoused vs. Housed Individuals in the Burn ICU
Authors: Kantor Paul
Published: April 2024

Introduction

Decreasing LOS by one day can decrease the cost of a hospital stay by 3% (Taheri et al., 2000). Several factors contribute to LOS in the BICU, including, but not limited to, age, comorbidities, acuity, treatment, exit strategy, and housing situation. The purpose of this study is to identify LOS differences between housing situations amongst BICU patients. Housing situations can delay or assist with LOS; unhoused individuals may experience a more complex exit strategy as compared with housed individuals, leading to greater LOS.

Methods

A retrospective analysis utilizing the national burn database to gather information about discharged patients from TMMC BICU between 2018-2023. Factors such as age, gender, degree of burn, amount of burn (Total body surface area % [TBSA%]), and living situation were all considered.

Average LOS was calculated based on the patient’s documented housing situation. The total number of hospital days was divided by the number of patients in that category to calculate the average hospital days per patient. LOS Without Surgery population (n) total 475. LOS 2018-2023 n = 317.

Results

A comparative analysis of Burn Registry data showed burn inpatients had longer LOSs compared to other inpatient burn groups LOSs of unhoused BICU inpatients averaged 2.8 days longer than housed patients.

Conclusions

The cause of the prolonged LOS in unhoused populations is difficult to ascertain. Difficulties in arranging wound care and placement is a difficult task to complete by case management. Psychiatric and/or complicated medical histories contributed to delays in discharge, prompting opportunity for future research (Ikebuchi et al., 2008). Literature fails to provide consistent causative/correlational data for the length of stay amongst the burn population in the hospital setting. Current studies show that age, socioeconomic factors, comorbidities, antibiotic use, and burn severity/TBSA contribute to LOS in the burn population (Chukamei et al., 2021).

Applicability of Research to Practice

Discharge planning should be initiated on the date of admission; special populations should be monitored more closely. Delays in discharge medication, wound care plans, and wound care supplies are intricate in these populations; research should be conducted into what causes these delays and what communication break downs between nursing, surgeons, and other ancillary staff prevent discharge. Involving a multidisciplinary approach would augment a safer and more expedited discharge for these complex patient populations. Future causative research is needed exploring reasons for discharge delays by examining interdisciplinary workflow communications that may contribute to delayed discharges.
603 A Burn Survivor- & Burn Community Stakeholder-Generated & Prioritized Research Agenda
Authors: Thompson Callie M , Webb Crystal D , Lewis Giavonni M , Prazak Ann Marie B , Quinn Kristen C
Published: April 2024

Introduction

Burn survivors are involved in burn research but typically as a research subject. We believe that the outcomes & impact of burn research can be improved by engaging survivors as collaborators in the planning, implementation, & dissemination of burn research. The goal of the work presented here was to produce the first research agenda generated & prioritized by burn survivors & other invested members of our burn community.

Methods

A research collaborative with a focus of co-production with burn survivors was formed in early 2022. This collaborative is run by governance committees, the majority of whom are burn survivors. Other members of the governance are family members & caregivers of burn survivors, & members of the burn community. The first goal of the collaborative was to form a stakeholder-generated & prioritized agenda for future burn research. The collaborative decided on 4 broad topics for Engagement Sessions (ES) in addition to a 5th topic of “Barriers to Participate in Research”. We then held 16 separate ES with burn survivors & their caregivers. The collaborative leadership then identified specific research questions/topics from the ES transcripts & prioritized those questions via anonymous survey. Notably, all participants in the ES & all committee members were compensated for their time.

Results

In over 26 hours of ES, 117 participants shared their thoughts on 5 broad topics: patient & family education, aftercare, navigating the healthcare system, recovery-physical & psychosocial, & barriers to research participation. From these sessions, 37 research question/topics were identified & ranked. In addition, 19 research barriers were identified & ranked. The top 10 research topics/questions are shown in Table 1. The top 3 barriers to research were: timing for researchers & survivors doesn’t line up (ex: researchers want to study 2 weeks after injury but patients are not in a place to participate), lack of understanding of the expected outcome or benefit, & lack of resources to have bandwidth to participate.

Conclusions

Burn survivors & their caregivers are experts in their lived experiences. By involving them in burn research as collaborators & contributors from the very first steps of research & throughout the continuum of planning, implementing, & dissemination of findings, we believe that the research will be both more successful & more impactful. We have taken the first steps to form the first co-produced collaborative & the first stakeholder generated research agenda for the burn community.

Applicability of Research to Practice

Our research collaborative is a well-informed & invested group that can participate in future studies. This research agenda will be readily available & all are encouraged to answer the questions that our burn survivors have identified to be the most pressing.
709 Scar-Related Outcomes in Burn Patients with Heterotopic Ossification
Authors: Sim Danielle J , Kuo Keith T , Caffrey Julie A
Published: April 2024

Introduction

Heterotopic ossification (HO) and aberrant scar formation are pathologic wound healing processes that may occur after burns. Hypertrophic scars occur in up to 70% of burn patients and can negatively affect quality of life. HO is characterized by the development of osseous lesions in the soft tissue and occurs in about 3.5% of burn patients, causing significant pain and delays in rehabilitation. Burns can incite a prolonged systemic inflammatory response involving innate and adaptive immune mediators, and this process has been shown to play a role in the development of both hypertrophic and keloid scars as well as HO. TGF-β1-producing macrophages are also implicated in excess extracellular matrix deposition and osteogenic differentiation in pathologic scarring and HO, respectively. Given the similar biologic mechanisms involved in these sequelae, this study aims to identify the clinical impact of HO on scarring in burn patients.

Methods

The Burn Model System (BMS) National Database was queried from August 1, 2015 - May 2, 2022 to identify adult patients (=>18 years) with and without HO at discharge. Patients with a burn etiology other than thermal, acid, or electrical were excluded. RStudio 4.3.0 (Posit, Boston, MA) was used for statistical analyses.

Results

In this sample, 135 (3.3%) patients had HO at discharge. The HO group was younger and exhibited a greater proportion of flame burns compared to non-HO group. The HO sample also had a larger average %TBSA and a higher incidence of other injuries.

On multivariate logistic regression, after controlling for sex, age, other injuries, and etiology, HO patients were more likely to have surgery for scar management at least once during the 24-month follow-up period (OR 2.43, 95% CI: 1.43—4.04, p< 0.001). HO patients were also more likely to report use of medications for itch symptoms (OR 1.80, 95% CI: 1.00—3.05, p = 0.0382). There was no difference in the incidence of pruritis between the two groups.

Conclusions

Patients with HO sustained more severe injuries than non-HO patients and required more frequent surgical and medical scar management. The increased use of itch medications suggests that HO patients experienced more severe symptoms despite having a similar incidence in pruritis overall. Therefore, HO is associated with worse scar outcomes after burns, potentially through immune-related mechanisms involved in both processes. Pruritis may also be related to a prolonged systemic inflammatory response as it is stimulated by cytokine IL-31 via induction of TGF-β1. Future research should identify methods of attenuating the immune response to prevent these sequelae without compromising wound healing or infection control.

Applicability of Research to Practice

This study advocates for increased awareness of symptomatic scarring in patients with HO. It also indicates the need to develop an immunomodulatory approach for reducing the risk of pathologic wound healing sequelae.
712 Outcomes of Transplants with CEA Derived from a Modified Composite Culture Technique: A Case Series
Authors: Kleintjes Wayne G , Prinsloo Tarryn K
Published: April 2024

Introduction

Establishing low-cost and efficient culture environments comparable to standard techniques would undoubtedly improve technique usage in under-resourced settings. The aim of this prospective, cohort case series was to report on the CEA graft-take using a modified culture technique that could benefit under-resourced clinical environments in terms of CEA accessibility and expense.

Methods

Burn patients (n=25) with low survival prognosis, large total body surface area (TBSA), and/or exhausted donor sites were transplanted with CEA grown on routinely used hydrophobic gauze in a pediatric incubator. Transplants occurred at our specialized Burns Centre between October 2014 and March 2016, following emergency ethical approval. Keratinocytes were retrieved from 3 x 2 cm full-thickness skin biopsies, placed in trypsin solution, and seeded onto the gauze. The cells were incubated in pediatric incubators at 37 °C and fresh autogenous plasma was applied daily while Intrasite gel® every third or fourth day until confluency on day 14 was reached. CEA was transplanted onto the debrided wound beds. Xenografts were used for temporary cover during the culture period. Graft take was assessed on burns patients that survived after the CEA transplant for ≥ 21 days (final assessment). The primary outcome was graft take, calculated as a surface area percentage of skin graft to CEA and the secondary outcome was main complications (nutrition, perineum burns, and hypoxic brain). Central indices were described as mean (95% CI) and/or frequency (%) for the following parameters: age, %TBSA, abbreviated burn severity index (ABSI) scores, % survival relative to ABSI and % graft take.

Results

Eleven patients (44%) survived until the final assessment (mortality occurred during the culture period), however, one case was excluded since treatment was for cosmetic purposes. Of the transplant cases, 10 out of 11 patients survived. A mean age of 36.1 years (95% CI 25.8-46.4), 45.0 %TBSA burns (95% CI 35.1-54.9), 9.7 ABSI scores (95% CI 8.6-10.8) and 79.5% graft take (95% CI) was observed. Reduced graft take (61.2%) was observed in patients with perineum burns compared to those with the remaining reported complications (91.8%).

Conclusions

CEA graft take was 79.5% using a low-cost culture technique was comparable to the largest CEA-based case series in literature. The survival of the major burn cases was highly favourable considering the severity of injuries, expected outcomes without CEA and the reported challenges.

Applicability of Research to Practice

Consistent graft take with a reliable, low-cost CEA method has been elusive until this method was applied in our setting. There is a potential for this method to be applicable in other settings as well and therefore make a value contribution to the accessibility of CEAs in general.
731 A Distressing Trend: Increased Prevalence of Self-Immolation Burns in a Single Burn Center
Authors: Hollowell Jamie L , Maxwell Eli , King Booker , Williams Felicia
Published: April 2024

Introduction

Attempting suicide via self-immolation is one of the more traumatic injuries leading to burn center admission. Patients with acute or acute-on-chronic suicidality are now faced with coping with a new trauma, and often were poorly resourced prior to burn center admission. These patients require a multidisciplinary approach to optimize their healing while addressing their mental health. We aimed to describe the increase in prevalence of self-immolation burns in our burn center.

Methods

Patients were identified using the Institutional Burn Center registry and linked to the clinical and administrative data. All patients admitted to the BICU between January 1, 2018, to Sept 30, 2023, were included. Demographics, length of stay (LOS), co-morbid conditions, and mortality were evaluated.

Results

There were a total of 45 patients over the 5-year, 9 month period. There were six self-immolations each year for 2018-2020. There were eight self-immolation admissions for 2021, nine for 2022, and ten for 2023, as of September 30, 2023. The patients were majority male, with 31 males and 14 females; average age was 35.4, (12-69); average TBSA was 21% (0 to 95%), most common etiology was flame with accelerant.

Conclusions

There continues to be a mismatch between the need for and access to mental health providers and resources in the community at large, leading to an yearly increase in the frequency of self-immolation admissions in our burn unit. These patients present unique challenges that require multidisciplinary coordination, with many patients still lacking appropriate disposition at discharge, taking up valuable burn center beds. Self-immolation as a form of suicide adds a new layer of emotional trauma for the patient, and often for the staff, which can make their recovery and rehabilitation that much more difficult. The ongoing mental health crisis in our country will likely see a further increase in these tragic injuries and the burn community needs to develop additional prevention and treatment strategies for this population.

Applicability of Research to Practice

This study reinforces the need for additional mental health resources with enhanced access for the community at large. The increased admission rate demonstrates an ongoing need for psychiatric care in the at-risk burn trauma population.
735 Grill-Related Burns: A Matched Cohort Study
Authors: Choe Deborah , Cooper Michael N , Roberts Miki , Gillenwater Justin , Yenikomshian Haig A
Published: April 2024

Introduction

Barbequing is a ubiquitous American pastime. However, unsafe practices involving this can result in devastating burn injury. Grills require a fuel source and an ignition which can be causes of injury. No US study to date has investigated the etiology of grill-related burns. This study aims to characterize the demographics, injury characteristics, and outcomes of grill-related burns and to identify ways of burn prevention.

Methods

A retrospective review of patients admitted to a single-institution burn center from 1/1/17 - 7/1/23. Data included demographics, comorbidities, burn etiology, location, severity, hospitalization characteristics, and outcomes. Each grill cohort (G Cohort) patient was matched to a non-grill control by mBaux score and burn location. A random number generator was used when multiple controls met matching criteria.

Results

Out of 2,355 patients, 69 (2.9%) met inclusion criteria. The G Cohort had 55 (79.7%) males and 5 (7.2%) pediatric patients. The average age was 41.7 ± 17.5 years old. A total of 20 (29.0%) grill-related burns occurred during Jun. - Aug. and 8 (11.6%) during Dec. - Feb. At time of admission, 25 (36.2%) patients had positive blood alcohol, 8 (11.6%) tested positive for amphetamine and 5 (7.2%) tested positive for cocaine. A total of 61 (88.4%) burns involved the upper extremity, 43 (62.3%) the head/neck, 34 (49.3%) the lower extremity, and 30 (43.5%) the trunk. A total of 24 (34.8%) burns were due to propane tank explosion, 18 (26.1%) related to lighter fluid use with 5 (7.2%) of them due to using gasoline or ethanol substitutes, 16 (23.2%) due to general flame injury, 9 (13.0%) due to contact burns, and 2 (2.9%) due to chemical burns related to grill cleaning solution. Compared to control, the G Cohort had greater proportions of male (79.7% vs. 62.3%, p< 0.05) and Hispanic/Latino patients (50.7% vs. 34.8%, p< 0.05) and a smaller proportion of Asians (2.9% vs. 10.1%, p< 0.05). The G Cohort had smaller proportions of patients who were undomiciled (11.6% vs. 30.4%, p< 0.01) or had a history of mental illness (5.8% vs. 17.4%, p< 0.05). Grill-related burns, which required fewer surgeries on average (1.4 ± 0.7 vs. 2.3 ± 1.9, p< 0.05), had a greater proportion of flash/flame burns (79.7% vs 55.1%, p< 0.01), with no differences in burn depth, hospital length of stay, ICU admission, readmission, or mortality rates.

Conclusions

This study suggests that middle-aged, domiciled males without psychiatric comorbidities are more likely to make preventable grilling errors resulting in burn injuries. Prevention strategies targeting this demographic should underscore the risks of grilling while intoxicated, proper handling of propane tanks and lighter fluid, and the importance of using flash/flame-resistant gear protecting the upper extremities and head/neck.

Applicability of Research to Practice

This study enhances our understanding of grill-related burns and ways to develop effective preventative strategies.
767 Preoperative Edema Management for the Burned Hand
Authors: Lucio J Xavier , Anyan Walter R , DuRose Lily , Ellsworth Madelyn P , Fleming Irma D , Lewis Giavonni M , Thompson Callie M , LaChapelle Christopher R
Published: April 2024

Introduction

At admission, we manage hand burns in four ways: (1) pre-operative hand edema control through elevation and application of ace bandages over the dorsal hand, (2) range of motion (ROM) protocols based on injury depth are used to restrict ROM to the digits to avoid injury to the ligamentous/tendinous structures of the hand/digit, (3) use of an intrinsic plus position hand splint, and (4) applying a silver sulfadiazine, gauze and netting dressing.

This practice has done an unsatisfactory job at reducing hand edema, resulted in prolonged immobilization and ROM restrictions, limited our patients’ ability to use their hands immediately post injury and ultimately lead to suboptimal functional outcomes at discharge.

As result, our center initiated a more aggressive pre-operative edema management plan which includes a preoperative self-adherent compression dressing (SACD) and a consistent practice for hand elevation.

Methods

Upon admission, a thorough hand assessment is done. Edema management is started within 24 hours of admit. The hand injury is placed in clear antibiotic ointment and SACD. Elevation is managed with pillows stacked so the hand is consistently above the bedrail. Figure of 8 measurements are taken every other day when SACD is changed. This process continues until the edema has stabilized at which time a glove compression is applied. If edema increases after the glove compression is started, the patient returns to a SACD until the edema remains stable.

Results

A total of 10 patients were treated with this protocol (8 B hands, 2 R hands, 18 hands total). All subjects were right hand dominant, nine males, and ages ranged from 17-74 years of age. TBSA burn ranged from 1-24% with (n=6) having TBSA < 10%. Split thickness autograft was placed on 16 hands (9R/7L). Figure of 8 values decreased during the pre- and post-operative phases of care (Table 1). No hand infections were noted. Composite flexion was improved at D/C: 12 hands (67%) able to make a full composite fist, 4 hands (22%) unable and 2 hands (11%) were not allowed to attempt due to ROM restriction per the surgeon (Figure 1).

Conclusions

This approach better manages edema associated with all depths of hand burns and leads to better functional outcomes at D/C.

Applicability of Research to Practice

We anticipate that this practice will allow us to move beyond our restrictive ROM protocols and reconsider pre-operative splinting practices. Which, in turn, will allow us to be able to progress patients' hand function more rapidly.
790 A Single Institution’s Surgical Model for Pediatric Burns with ≤ 10% Body Surface Area Involvement
Authors: Fish Joel , Lee David , Chakera Hawwa , Kelly Charis , Zuccaro Jennifer
Published: April 2024

Introduction

Burn injuries continue to be prevalent in the pediatric population and are the fifth most common cause of non-fatal injury according to the World Health Organization. Unlike the adult population, most pediatric burns in the United States are small in size and are often the result of scalds. Despite the high incidence of small burns, a standardized treatment algorithm does not currently exist, and care is often influenced by clinical judgement and resource availability. As a result, various techniques to close the burn wound and promote further healing are currently utilized. This study explores the utility of a multi-stage grafting technique, involving allograft and autograft, for treating small burns (≤ 10% total body surface area (TBSA)) in pediatric patients.

Methods

A retrospective review of patients aged 0-18 years who had a burn that was ≤ 10% TBSA and underwent a multi-stage grafting procedure involving the use of allograft and autograft between 09-01-2018 and 09-01-2022 was conducted. Demographic information including data pertaining to the burn injury was collected for all patients. The primary outcome measure for this study was the percentage of graft take at the graft dressing takedown procedure. All variables were summarized using descriptive statistics. P values < 0.05 indicated statistical significance.

Results

One hundred and sixty-eight patients met the inclusion criteria for this study. The mean time from presentation to allograft surgery was 10.8 days (SD 5.6) followed by autograft surgery approximately one week later. Most patients were discharged within 24 hours following allograft surgery (88.1%) and autograft surgery (80.9%). Mean autograft take was 97.7% (SD 11.1%) with only four patients experiencing significant graft loss requiring subsequent re-grafting. The main causes of graft loss were infection and inadequate excision of the wound bed.

Conclusions

This analysis revealed that patients who underwent a multi-stage grafting procedure involving the use of allograft and autograft experienced minimal graft loss. These positive outcomes demonstrate that the multi-stage grafting technique, which has traditionally been employed for larger burn injuries, can be successfully adapted for smaller burns in children. Moreover, the findings from this study help to address the significant knowledge gap regarding the optimal approach to treating small burn wounds. Further research in this area is warranted to learn more about cosmetic outcomes following multi-stage grafting and determine how it compares to other techniques for treating small burns.

Applicability of Research to Practice

The findings from this study will allow us to begin benchmarking our treatment of small burn wounds with other centers resulting in improvements in patient care and outcomes.
Persistent homology reveals strong phylogenetic signal in 3D protein structures
Authors: Bou Dagher Léa , Madern Dominique , Malbos Philippe , Brochier-Armanet Céline
Published: April 2024

Changes that occur in proteins over time provide a phylogenetic signal that can be used to decipher their evolutionary history and the relationships between organisms. Sequence comparison is the most common way to access this phylogenetic signal, while those based on 3D structure comparisons are still in their infancy. In this study, we propose an effective approach based on Persistent Homology Theory (PH) to extract the phylogenetic information contained in protein structures. PH provides efficient and robust algorithms for extracting and comparing geometric features from noisy datasets at different spatial resolutions. PH has a growing number of applications in the life sciences, including the study of proteins (e.g. classification, folding). However, it has never been used to study the phylogenetic signal they may contain. Here, using 518 protein families, representing 22,940 protein sequences and structures, from 10 major taxonomic groups, we show that distances calculated with PH from protein structures correlate strongly with phylogenetic distances calculated from protein sequences, at both small and large evolutionary scales. We test several methods for calculating PH distances and propose some refinements to improve their relevance for addressing evolutionary questions. This work opens up new perspectives in evolutionary biology by proposing an efficient way to access the phylogenetic signal contained in protein structures, as well as future developments of topological analysis in the life sciences.
Jurisdiction in Switzerland in cross-border successions
Authors: Weiss Kinga M , Müller-Zhang Michael
Published: April 2024

When a legal dispute has an international or so-called “cross-border” connection before the Swiss courts or authorities, the private international law of Switzerland (codified in the Federal Act on Private International Law) determines whether Swiss courts and authorities have jurisdiction, which substantive law is applicable, and the recognition and enforcement of foreign decisions, measures, deeds, and rights. In Swiss international law, “residence” is the main connecting factor. Thus, the terminology of “residence” is to be defined, as it is typically the entry point of any case heard in Switzerland, which does not necessarily follow the tax authorities’ or other authorities’ assessment or tax rulings for residency. In recent years, the Federal Supreme Court has had the chance to decide on various cases where residence in cross-border inheritance cases was disputed and some findings led to unexpected and unintended results.
Assessment of Rehabilitation Practices During Hematopoietic Stem Cell Transplantation in the United States: A Survey
Authors: Leite Victor F. , Oza Sonal , Parke Sara C. , Barksdale Touré , Herbert Aliea E. , Bansal Vishal , Fu Jack B. , Ngo-Huang An
Published: April 2024

Background:

Rehabilitation therapy is important to treat physical and functional impairments that may occur in individuals receiving physically taxing, yet potentially curative hematopoietic stem cell transplants (HSCTs). However, there are scarce data on how rehabilitation is delivered during HSCT in real-life setting. Our objective is to assess the rehabilitation practices for adult patients hospitalized for HSCT in the United States.

Methods:

We conducted a 48-question online survey with cancer centers with the top 10% HSCT volumes (per American registries). We obtained data on patient characteristics, rehabilitation therapy details (timing, indication, and administering providers), physical function objective and subjective outcome measures, and therapy activity precautions.

Results:

Out of 21 institutions, 14 were included. Rehabilitation therapy referrals occurred at admission for all patients at 35.7% of the centers for: functional decline (92.9%), fall risk (71.4%), and discharge planning (71.4%). Participating institutions had physical therapists (92.9%), occupational therapists (85.7%), speech-language pathologists (64.3%), and therapy aides (35.7%) in their rehabilitation team. Approximately 71% of centers used objective functional measures including sit-to-stand tests (50.0%), balance measures (42.9%), and 6-minute walk/gait speed (both 35.7%). Monitoring of blood counts to determine therapy modalities frequently occurred and therapies held for low platelet or hemoglobin values, but absolute neutrophil values were not a barrier to participate in resistance or aerobic therapies (42.9%).

Conclusion:

Rehabilitation practices during HSCT varied among the largest volume cancer centers in the United States, but most centers provided skilled therapy, utilized objective, clinician- and patient-reported outcomes, and monitored blood counts for safety of therapy administration.
Association between Colonoscopy Sedation Type and Polyp Detection: A Registry-based Cohort Study
Authors: Quaye Aurora N. , Hisey William M. , Mackenzie Todd A. , Robinson Christina M. , Richard Janelle M. , Anderson Joseph C. , Warters Robert D. , Butterly Lynn F.
Published: April 2024

Background

Colorectal cancer is a leading cause of cancer-related death. Adenomas and serrated polyps are precursors of colorectal cancer, with serrated polyps being more difficult to detect during colonoscopy. The relationship between propofol use and polyp detection remains unclear. The authors investigated the association of propofol-based versus mild–moderate sedation on adenoma and serrated polyp detection during colonoscopy.

Methods

This retrospective cohort study used observational data from the New Hampshire Colonoscopy Registry. Patients aged greater than 50 yr with screening or surveillance colonoscopies between January 1, 2015, and February 28, 2020, were included. Exclusions were diagnostic examinations, no sedation, missing pathology data, and poor bowel preparation. Multivariate logistic regression was used to evaluate differences in polyp detection between propofol and moderate sedation in the full sample while adjusting for covariates. Propensity score adjustment and clustering at the endoscopist level were used in a restricted sample analysis that included endoscopists and facilities with between 5% and 95% propofol sedation use.

Results

A total of 54,063 colonoscopies were analyzed in the full sample and 18,998 in the restricted sample. Serrated polyp prevalence was significantly higher using propofol (9,957 of 29,312; 34.0% [95% CI, 33.4 to 34.5%]) versus moderate sedation (6,066 of 24,751; 24.5% [95% CI, 24.0 to 25.1%]) in the full sample and restricted samples (1,410 of 4,661; 30.3% [95% CI, 28.9 to 31.6%] vs. 3,690 of 14,337; 25.7% [95% CI, 25.0 to 26.5%]). In the full sample multivariate logistic regression, propofol was associated with higher neoplasm (adjusted odds ratio, 1.25 [95% CI, 1.21 to 1.29]), adenoma (odds ratio, 1.07 [95% CI, 1.03 to 1.11]), and serrated polyp detection (odds ratio, 1.51 [95% CI, 1.46 to 1.57]). In the restricted sample using inverse probability of treatment weighted propensity score adjustment and clustering at the endoscopist level, an attenuated but statistically significant effect size was observed for serrated polyps (odds ratio, 1.13 [95% CI, 1.07 to 1.19]), but not for adenomas (odds ratio, 1.00 [95% CI, 0.95 to 1.05]) or any neoplastic lesion (odds ratio, 1.03 [95% CI, 0.98 to 1.08]).

Conclusions

Propofol sedation during colonoscopy may be associated with improved detection of serrated polyps, but not adenomas.

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Comparing serial and current liver stiffness measurements to predict decompensation in compensated advanced chronic liver disease patients
Authors: Wong Yu Jun , Chen Vincent L. , Abdulhamid Asim , Tosetti Giulia , Navadurong Huttakan , Kaewdech Apichat , Cristiu Jessica , Song Michael , Devan Pooja , Tiong Kai Le Ashley , Neo Jean Ee , Prasoppokakorn Thaninee , Sripongpun Pimsiri , Stedman Catherine Ann Malcolm , Treeprasertsuk Sombat , Primignani Massimo , Ngu Jing Hieng , Abraldes Juan G.
Published: April 2024

Background and Aims:

The utility of serial liver stiffness measurements (LSM) to predict decompensation in patients with compensated advanced chronic liver disease (cACLD) remains unclear. We aimed to validate whether comparing serial LSM is superior to using the current LSM to predict liver-related events (LRE) in patients with cACLD.

Approach and Results:

In this retrospective analysis of an international registry, patients with cACLD and serial LSM were followed up until index LRE. We compared the performance of both the dynamic LSM changes and the current LSM in predicting LRE using Cox regression analysis, considering time zero of follow-up as the date of latest liver stiffness measurement. Overall, 480 patients with cACLD with serial LSM were included from 5 countries. The commonest etiology of cACLD was viral (53%) and MASLD (34%). Over a median follow-up of 68 (IQR: 45-92) months, 32% experienced a LSM decrease to levels below 10kPa (resolved cACLD) and 5.8% experienced LRE. Resolved cACLD were more likely to be non-diabetic and had better liver function. While a higher value of the current LSM was associated with higher LREs, LSM changes over time (LSM slope) were not associated with LRE. In multivariable Cox regression, neither the prior LSM nor the LSM slope added predictive value to latest liver stiffness measurement.

Conclusions:

Once the current LSM is known, previous LSM values do not add to the prediction of LREs in patients with cACLD.
SUPRACHOROIDAL TRIAMCINOLONE ACETONIDE FOR REFRACTORY POSTOPERATIVE CYSTOID MACULAR EDEMA
Authors: Momenaei Bita , Pandit Saagar A. , Wang Kristine Y. , Wakabayashi Taku , Hsu Jason , Regillo Carl D. , Klufas Michael A. , Xu David , Cohen Michael N. , Garg Sunir J. , Kuriyan Ajay E. , Yonekawa Yoshihiro
Published: April 2024

Purpose:

To investigate outcomes of suprachoroidal triamcinolone acetonide (XIPERE, Bausch + Lomb) for the treatment of refractory postoperative cystoid macular edema.

Methods:

Medical records of patients receiving suprachoroidal triamcinolone acetonide for postoperative cystoid macular edema were reviewed. Primary outcomes were visual acuity and central foveal thickness.

Results:

A total of 32 eyes from 32 patients with a median (interquartile range) follow-up duration of 6 (2–7) months and 1 (1–2) suprachoroidal triamcinolone acetonide injection were included; 19 (59.4%) had a history of vitrectomy. The median (interquartile range) central foveal thickness decreased from 492 (379–629) µm to 267 (187–388) µm at 1 month (P < 0.001), 362 (218–521) µm at 3 months (P = 0.005), and 339 (206–514) µm at the final visit (P < 0.001). The median logarithm of the minimal angle of resolution visual acuity improved from 0.65 (0.48–0.97, 20/89) at baseline to 0.54 (0.35–0.88, 20/69) (P = 0.058) at 1 month, 0.54 (0.33–0.84, 20/69) at 3 months (P = 0.121), and 0.60 (0.33–0.88, 20/80) at the final visit (P = 0.021). Vitrectomized eyes had similar findings. Six eyes (18.8%) developed elevated intraocular pressure (>24 mmHg) (range: 25–49 mmHg) with a median intraocular pressure elevation of 13.5 mmHg compared with baseline, and all had prior glaucoma or ocular hypertension.

Conclusion:

Suprachoroidal triamcinolone acetonide reduced macular edema and improved vision in refractory postoperative cystoid macular edema, including vitrectomized eyes. Intraocular pressure should be monitored, especially in those with a history of glaucoma or ocular hypertension.
Hematuria Due to Possible Histoplasma-Associated Urinary Bladder Pseudotumor With Negative Serologic and Urine Antigen Testing
Authors: Aggarwal Abhimanyu , Mills Corey , Frankenberger Kyle , Greenstein Adam , Nelson Benjamin , Hatem Fadi , Blue Deborah E. , Wheat L. Joseph , Yamshchikov Alexandra
Published: April 2024

Histoplasma capsulatum is a ubiquitous dimorphic fungus causing multiple infectious syndromes, ranging from subclinical to severe disseminated disease. We present an unusual case of hematuria due to pedunculated urinary bladder mass in an immunocompetent host. Although the gold standard for diagnosis of histoplasmosis is through demonstration of characteristic yeast forms on histopathologic examination of infected tissue, or observation of typical mycelial growth in culture of clinical specimens, investigational multiplex polymerase chain reaction of formalinized tissue was helpful in this case due to conflicting serologic testing, equivocal morphologic findings on histopathologic examination and, surprisingly, a negative urine Histoplasma antigen despite anatomically proximal location within the urinary bladder. Although antigen immunoassay and serology are commonly used proxy diagnostics in Histoplasma-associated disease, varying performance characteristics in certain disease states, such as cases of locally proliferative infection mimicking neoplastic growth similar to this report, may lead to elusive diagnosis.