bluuebunny/crossref_metadata_2025_split huggingface dataset:
2 Impact of Multimodal Analgesia on Critically Ill Burn Patients
Authors: Young Sierra R , Duby Jeremiah , Louie Erin 
Published: March 2020

Abstract

Introduction
Opioids are considered the cornerstone of treatment for post-operative burn pain. However, detrimental adverse effects of opioid use include over-sedation, respiratory depression and dependence. Multimodal analgesia is an alternative method of pain control that utilizes a combination of opioid and non-opioid medications. Multimodal analgesia offers different mechanisms of action which may be beneficial in burn-injured patients. This study examines the impact of multimodal therapy for post-operative pain control in a burn intensive care unit (BICU).

Methods
This retrospective cohort study was performed at an academic burn center between 2012 and 2018. Consecutively admitted patients with burns greater than or equal to 10% total body surface area (TBSA) and BICU length of stay (LOS) greater than seven days were eligible for inclusion. Patients were excluded if they received an opioid continuous infusion greater than 48 hours. Patients treated with multimodal analgesia were compared to those treated with opioids alone. The total oral morphine equivalent (OME) dose was calculated for each 24-hour period for 5 days after a grafting surgery. Secondary endpoints included pain scores, BICU LOS, and ventilator days. Data analysis was performed with descriptive statistics. A power calculation determined that 60 patients per group were needed to detect a 30% difference in the primary endpoint.

Results
There were 100 patients in the non-multimodal group and 100 patients in the multimodal group. Mean cumulative OME dose was significantly lower in the multimodal group (1,028 mg vs. 1,438 mg, P &lt; 0.002). Patients with over 20% TBSA burns had a larger reduction in mean OME doses in the multimodal group (1,097 mg vs. 1,624 mg, P = 0.0049) compared to patients with 10% to 20% TBSA burns (949 mg vs 1,282 mg, P = 0.057). Utilizing more multimodal agents was not associated with lower OME doses. There was no difference in pain score on post-operative day 5 (5.5 + 2.3 vs. 6.2 + 2.2, P=0.07) or at ICU discharge (4.7 + 2.4 vs 4.7 + 2.8, P = 0.99). There was no difference in other secondary outcomes.

Conclusions
The use of multimodal analgesia significantly reduced cumulative OME doses without compromising pain control.

Applicability of Research to Practice
Multimodal analgesia may be a beneficial adjunct to burn pain management to mitigate opioid use without compromising pain control.
5 The Predictive Capacity of ASA PS in Burn Patients
Authors: Choi Katherine J , Pham Christopher H , Collier Zachary J , Mert Melissa , Ota Ryan K , Li Ruibei , Yenikomshian Haig A , Gillenwater Justin , Kuza Catherine 
Published: March 2020

Abstract

Introduction
The four main prognostic models used to determine risk of burn mortality are the revised Baux (rBaux), Belgian Outcome in Burn Injury (BOBI), Abbreviated Burn Severity Index (ABSI), and quick Sequential Organ Failure Assessment (qSOFA). These models fail to factor in medical comorbidities. The ASA PS (American Society of Anesthesiologists Physical Status) is a simple scale incorporating severity of traumatic injury with comorbidities, which strongly predicts mortality in surgical patients. The purpose of this study is to determine whether the ASA PS is an adequate adjunct to measure burn severity.

Methods
All adults admitted to an ABA verified burn center from January 2016 to April 2019 with TBSA ≥10% who underwent surgery were reviewed. Demographics (age, gender, TBSA, race, ASA PS), vital signs (GCS, blood pressure, respiratory rate), and outcome variables (length of stay [LOS], mechanical ventilation [MV] days, and complications) were evaluated. rBaux, BOBI, ABSI, and qSOFA scores were calculated. The primary outcome was in-hospital mortality. After descriptive statistical analysis, mortality associations of the models were assessed by determining odds ratios. Firth’s logistic regression and area under the receiver operator curves determined the predictive utility of the prognostic scores.

Results
Of the 183 patients who fit inclusion criteria, median age was 44 years (30–57), and the majority (70%) were male. Median TBSA was 20%, 65% (n=118) had full thickness burns, 14% (n=25) had inhalation injury, and mortality was 9% (n=17). rBaux score was the best predictor of mortality (AUC=.84), ICU LOS (R2=.04), and MV days (R2=.06). For every 10-point increase in rBaux score, there was a 1.7 times increase in mortality (OR=1.7, CI 1.4–2.3, p&lt; .00). The predicted ICU LOS increases from 2.8 to 31.4 days for the lowest and highest rBaux score quartiles. Compared to rBaux scores of 30–53, patients with scores of 54–70 had 4 times more MV days (CI 1.5–11, p&lt; .00). The ASA PS was slightly inferior to rBaux in predicting mortality (AUC=.72), although not statistically significant (p=0.1). As ASA PS score went from I/II to III, III to IV, and IV to V/VI; mortality increased by 2.8 (OR=2.8, CI 1.5–5.5, p&lt; .00).

Conclusions
rBaux is the best predictor of mortality, ICU LOS, and MV days although ASA PS also predicts mortality. Future studies should determine the combined predictive ability of ASA PS and rBaux.

Applicability of Research to Practice
rBaux and ASA PS scores can be used to determine risk of mortality in burn patients.
14 Do Calorie Counts Alter Care or Outcomes in Burn Patients?
Authors: Shepler Amanda , Fagert Kayleigh , Cochran Amalia , Coffey Rebecca 
Published: March 2020

Abstract

Introduction
Calorie counts are often used as a monitoring tool for burn nutrition and require accurate documentation by staff for the nutritionist to properly evaluate and treat the patient. The objective of this project was to determine if completion of calorie counts positively impacts patient outcomes.

Methods
A quality improvement project was conducted on adult burn patients at a large academic medical center from June 2018 to March 2019. All burn patients with calorie count orders and an admission weight were included. The total number of meal trays with completed calorie count documentation was calculated on a weekly basis, generating a total weekly calorie count compliance rate (CCCR). Data collected included weight change from admission to discharge, standard nutrition labs, and if nutritional interventions were changed.

Results
A total of 76 adult burn patients with a documented admission weight were included. The average total body surface area (TBSA) burn injury was 10.9%. Average length of stay was 1.3 days/ %TBSA. Of the 9.2% of patients with admission and discharge weights, 14% had increased discharge weight (mean CCCR 43%) and 86% had a decrease in weight (mean CCCR 48%). Weekly total protein levels were obtained in 24 patients with 46% having decreased total protein levels (0.1 to 1.1 g/dL) and a mean CCCR of 74.4%. Eight percent had no change in protein levels with a mean CCCR of 74.3% and 46% had increased total protein levels (0.1 and 0.7 g/dL) with a mean CCCR of 70%. Weekly albumin levels were obtained in 25 patients. Fifty-two percent had decreased albumin levels (0.1 to 0.9 g/dL) with a mean CCCR of 72.1%. Twenty percent had no change in albumin level, with a mean CCCR of 75.1% and 28% of patients had increased albumin levels (0.1 to 0.6 g/dL) with a mean CCCR of 69%. Weekly prealbumin serum levels were obtained in 27 patients. Fifty-six percent had decreased levels (1 to 19 mg/dL) with a mean CCCR of 74.1%. Four percent had no change in serum prealbumin, with a mean CCCR of 69%, and 41% had increased prealbumin levels (1 to 21 mg/dL) with a mean CCCR of 68%. Nutritional therapy was altered in 6% of patients by addition of oral supplementation, dietary modifications, or initiation of tube feeding.

Conclusions
A very small number of patients on calorie counts had any change in nutritional therapy and calorie count compliance showed no relationship with nutrition labs. However, calorie counts are labor-intensive for nursing staff. Further research should be conducted to identify which patients would benefit from daily calorie counts in the burn patient.

Applicability of Research to Practice
Use of evidence-based outcome measures can drive clinical practice.
16 Clinical Outcomes in Patients with Diabetes, Prediabetes, and No Diabetes Following Acute Burn Injury
Authors: Coffey Rebecca , Zhelezny Richard V , Porter Kyle , Zhang Charles , Murphy Claire V 
Published: March 2020

Abstract

Introduction
Based on the National Burn Repository Data (2002–2011), the incidence of diabetes is increasing among adult patients with burn injury. Diabetes has been associated with increased morbidity and mortality following burn injury. There is limited data related to prediabetes in burn injury, and no studies to date have compared clinical outcomes in patients without diabetes, with prediabetes, and with diabetes. Therefore, this study aimed to compare the impact of diabetes status, defined as no diabetes (ND), prediabetes (PD), or diabetes (DM), on clinical outcomes after burn injury.

Methods
A single-center, retrospective cohort study of adult patients admitted for initial management of burn injury between January 1, 2009 and February 28, 2019 who had a hemoglobin A1c (HbA1c) upon admission was performed. Patients with chemical or electrical injury, isolated smoke inhalation injury, total body surface area (TBSA) burn injury &lt; 1%, patients who expired or transitioned to comfort care within 24 hours of admission, or were incarcerated or pregnant were excluded. Patients were categorized as ND, PD, or DM based on their past medical history and admission HbA1c. The primary outcome was LOS/%TBSA burn. Secondary outcomes included mortality, LOS, discharge disposition, re-grafting of same site, and amputations. Propensity score methods were used to account for imbalance between groups. Separate propensity score weights were calculated for analysis of DM versus ND and DM versus PD. The primary outcome LOS/%TBSA burn was compared between groups using weighted linear models. Since the outcome was right-skewed, LOS/%TBSA burn was log-transformed for analysis, yielding estimates of the ratio of geometric means.

Results
A total of 1137 patients were included (710 ND, 191 PD, 236 DM). Patients were predominately male (70.3% ND, 67.4% PD, 70.2% DM) and Caucasian (85.5% ND, 73.8% PD, 82.1% DM). The mean BMI was highest in DM (31.8 kg/m2) and lowest in ND (27.8 kg/m2). After inverse probability weighing to adjust for potentially confounding factors, DM had longer LOS/%TBSA burn than patients with ND (ratio of geometric means (95% CI) = 1.61 (1.21, 2.15), p = 0.001) or PD (ratio (95% CI) = 1.53 (1.14, 2.05), p =0.01). No differences in secondary outcomes were observed between the DM and ND groups and between DM and PD groups with the exception of amputations (2.8% DM vs. 0.7% ND, p=0.06; 2.6% DM vs. 0% PD, p=0.04).

Conclusions
Diabetes in the burn patient significantly increases LOS/%TBSA index and amputation rates compared to both PD and ND.

Applicability of Research to Practice
Diabetes may contribute to increased cost of care in burn injury. Early identification of diabetes status may aid management of this patient population.
19 Epidemiology of Acute Burn Admissions at a Referral Center in Nepal: A Comparison Between Direct Admissions and External Referrals
Authors: Mehta Kajal , Stewart Barclay T , Pham Tam N , Nakarmi Kiran K 
Published: March 2020

Abstract

Introduction
Nepal is a low-income country where burn injury is a leading cause of preventable deaths and disabilities. A major burn center was established in 2013 to care for patients with acute injuries and reconstruction needs from local and from distant communities. We aimed to characterize the epidemiology of admissions and patterns of referral to guide health system planning and efforts.

Methods
We described prospectively collected data from patients with acute burns from January 2016 to July 2019. Sociodemographic and injury data included age, sex, hospital of provenance or direct admission status, total burn surface area (TBSA), and presence of complications on admission (e.g., wound infection, sepsis). Outcomes included length of stay and mortality. Differences in proportions and medians were compared with Chi square and Wilcoxon Rank Sum tests, respectively.

Results
There were 1,813 patients admitted with acute burns over the study period. Median patient age was 26 years (IQR 12–45). More than half of patients were female (55%). Median TBSA was 15% (IQR 7–30%) with a median Baux score of 48 (IQR 27–75). Most patients were transferred from another facility (65% of admissions). Referrals came from over 300 facilities across the country. Referred patients had larger TBSA (median 16%, IQR 9–30%) compared to directly admitted patients (median 12%, IQR 5–30% (p=0.0001). Although median day post-burn day of presentation was 1 day for both groups, referrals had significant admission delays (IQR 0–7) compared to direct admissions (IQR 0–4, p=0.0001). An infection was present on admission in 5% of referrals compared to 2.4% of direct admissions (p=0.01). Median length of stay (among survivors) was longer for referrals (10 days, IQR 5–17) compared to 6 days (IQR 2–12) for direct admissions [p=0.001]). Mortality rate was relatively unchanged across the study period (23% in 2016, 21% in 2019, p=0.82). For patients with burn TBSA &gt;40%, inpatient mortality decreased from 76% in 2016 to 51% in 2019 (p=0.05), however there were few instances of hospital discharges with a palliative intent. There was no difference in mortality rate for referrals compared to direct admissions (21 vs 22%, p=0.63].

Conclusions
Despite significant delays in presentation and higher rates of infection on admission, mortality for referral patients was similar to directly admitted patients. Additionally, improvements in care quality have led to significant decreases in the mortality rate for large burns. These data suggest that regionalization of care in Nepal may successfully rescue and manage severe burns in a specialized center.

Applicability of Research to Practice
These data support regionalization of care for patients with burn injuries in Nepal. Further work to understand the epidemiology and care of patients who do not get referred is required to address system gaps.
20 The Global Burn Registry: A Work in Progress
Authors: Gibson Cameron J , Bessey Palmer Q , Gallagher James 
Published: March 2020

Abstract

Introduction
In 2018 the World Health Organization (WHO) launched the Global Burn Registry (GBR). Its purpose is to help improve the understanding of burn injury worldwide. The purpose of this study was to identify early findings from this database.

Methods
The GBR was accessed in September 2019. Cases from centers in low income (LIC) and low-middle income countries (LMIC) were combined into a Low Resource (LR) group, and cases in High Income (HIC) and Upper Middle Income (UMIC) countries were combined into a High Resource group (HR). Statistical analysis was performed with SAS 9.4. Data are expressed as mean ± SEM. Logistic Regression was used to identify risk factors for death. Revised Baux Score (RBS) was calculated as described by Osler (2010). Odds ratios are expressed as mean (95% confidence interval). The LA50 was calculated from the regression of death and total burn size (TBSA) for different age groups.

Results
At the time of analysis, there were 2,315 cases in the GBR treated at 23 facilities in 15 countries (4 HIC, 5 UMIC, 4 LIMC, and 2 LIC). There were 1,346 cases (58%) from HR countries and 969 (42%) from LR countries. The patients in LR were older than those in HR (26.2 ± 0.6 years vs 20.7 ± 0.6, p&lt; 0.01) and had larger TBSA burns (31.0 ± 0.8 % TBSA vs 16.6 ± 0.4, p&lt; 0.01). There were fewer scald burns and more flame injuries in the LR countries (26 ± 1.4 % vs 54 ± 1.4, and 56 ± 1.6 % vs 32 ± 1.3, p&lt; 0.01). Case fatality and RBS were greater in LR (31.5 ± 1.5 % vs 4.8 ± 0.6 and 61.4 ± 1.3 % vs 38.9 ± 0.9, p&lt; 0.01). In regression analysis, LR was an independent risk factor for death with an odds ratio of 6.3 (4.3 – 9.4). The LA50 for HR countries was similar to those in the National Burn Repository. For LR countries the LA50 was lower for all ages except those 65 and older, ranging from 30–45% TBSA.

Conclusions
Only a few facilities have contributed data to the GBR so far, with lower resourced countries less represented than higher resourced ones. The proportion of cases in the pediatric age group is much less represented in LR countries than in HR, possibly because many burned children in LR countries do not get burn care at specialized centers. Survival in HR countries is similar to that in North America. The GBR provides early insights into global burn care. Opportunities for improvement are greatest in LR countries. New Innovations may be necessary to increase participation from burn centers in LR countries.

Applicability of Research to Practice
This report provides an early look at burn care across the globe based on cases in the GBR. It may inform further efforts to characterize and improve burn care in low resourced countries.
30 Does Peer Support Facilitate Social Integration Following Burn Injury?
Authors: Holavanahalli Radha K , Roaten Kimberly , Sanchez Adriana 
Published: March 2020

Abstract

Introduction
Facilitating access to one-to-one peer support is an important criterion in providing aftercare for individuals with a burn injury. Although there is an increase in understanding of the perceived benefits of peer support, there are not many studies examining peer support as an intervention to promote community re-entry. This comparative study aims to examine if there is a difference in physical and mental health outcomes, including social reintegration between a group that received one-to-one peer support (PS) and a group that did not receive the peer support (NPS).

Methods
Subjects include adults (&gt;=18y) with a major burn injury who received treatment at a major burn center and consented to participate in a longitudinal national database at discharge from hospital, 6-, 12-, and 24-months post injury. The physical and mental health outcomes were measured using the SF-12 Health Questionnaire – Physical (PCS) and Mental (MCS) component (50 is the average score or norm); the Satisfaction with Life Scale, and Social Integration (SI) was measured by the Community Integration Questionnaire Social Component Scale (score range 0–12; 0 is no community integration and 12 is excellent community integration). The PS program offered at the burn center is a standardized program that includes an 8-hour peer volunteer training. Independent Samples t Tests were conducted to see if there were significant differences in health outcomes between the group that received PS and the group that did not receive PS (NPS).

Results
Over a period of 5 years, 228 subjects consented to participate in the database. Subjects were predominantly male (70%) and White (72%), with a mean age of 44 years and the mean total body surface area was 24.8%. Sixty-three (28%) subjects received peer visits during their stay in the hospital. Compared to the NPS group, the social integration score for the PS group was higher at all time points, although it was statistically significant only at 24 months (PS= 8.22, NPS=7.13, p&lt; .01). The PS group scored significantly higher in satisfaction with life at 6 months (p&lt; .01) and at 12 months (p&lt; .05). There were significant differences found in TBSA %burn (PS = 31%, NPS = 22%; p&lt; .001), average length of acute hospital stay (PS= 52 days, NPS = 31 days; p&lt; .01), and average length of in-patient rehabilitation stay (PS= 12 days, NPS = 5 days; p&lt; .05).

Conclusions
The social integration and satisfaction with life scores of the PS group was higher when compared to those of the NPS group. The study highlights the profile of patients who seek peer support visits and has implications for delivery and utilization of burn aftercare programs.

Applicability of Research to Practice
The study findings highlight the emerging need for providing burn survivors with resources such as peer support to facilitate successful community reentry, and examine the effects of such interventions on health outcomes.
48 Burn Injury Impedes Late Erythropoiesis via Decreased Alpha Hemoglobin Stabilizing Protein and siglec1
Authors: Muthumalaiappan Kuzhali , Walczak Julia , Johnson Camargo , Bunn Corinne 
Published: March 2020

Abstract

Introduction
Transfusions are of no benefit to burn patients with chronic anemia. We are elucidating the mechanisms of erythropoietin resistant anemia in burn injury using a mouse model in addition to a contrived system with human PBMCs. We have found that Alpha Hemoglobin Stabilizing Protein (AHSP), an erythroblast specific protein essential to effective hemoglobinization, is decreased in PBMC derived erythroblasts (EB) from burn patients (male + female). Hemoglobinization begins at the polychromatic EB (PolyE) stage and intensifies at the orthochromatic EB (OrthoE) stage, culminating in ejection of the nucleus and the cell becoming a reticulocyte (Reti). EB needs the support of a central island macrophage (EBI MØ) until they progress to maturation. We have seen in bone marrow from mice (male) following burn injury that Siglec1, an essential adhesion molecule is decreased in EBI MØ. It is these MØ that provide iron for the assembly of the hemoglobin unit in late erythropoiesis. EB maturation defects seen in burn injury could be due to the intrinsic changes in EB phenotype or the phenotype of supporting EBI MØ or a combination of the two. Our goal was to investigate in the animal model using male and female mice, how myeloid/erythroid intrinsic changes after burn impact the progression of late erythropoiesis from an EB and EBI MØ perspectives.

Methods
With IACUC approval, 12 male and female mice were anesthetized and subjected to sham burn or scald burn (15% TBSA) upon dorsal immersion in a 100oC water bath for 8 seconds. Animals were sacrificed on post burn day 7 (PBD 7). Total bone marrow cells (TBM) were harvested from bilateral femurs. Cells were characterized using CD71, Ter119, and Syto16 antibodies. EBI MØ were identified using a combination of F4/80, ERHR3, Vcam1, Ly6G and Siglec 1 antibodies. Geometric mean of fluorescence intensity (MFI) and cell counts were obtained by flow cytometric analysis and presented as x103 per million TBM cells. Peripheral blood was harvested via cardiac puncture and hemoglobin concentrations (g/dL) were obtained using a hematology analyzer.

Results
Among the erythroblasts, EEBs were 2.4 fold higher with a 2.4 fold lower AHSP expression in PBD 7 mice compared to sham as shown in left, top and bottom figures. Similarly, more EEBs were associated with EBIMØ with a lower Siglec1 expression as shown in right, top and bottom figures. Blood Hbg concentrations were lower in burn (sham=15.5±0.7 vs PBD 7= 13.1±0.5; p&lt; 0.01).

Conclusions
The combined influence of Siglec1 and AHSP expression interferes with effective hemoglobinization impeding late maturation of erythroblasts following burn injury. Whether there is a synergistic action between the two deficiencies is being studied.

Applicability of Research to Practice
Underpinning the mechanism of erythropoiesis will lead to better options to ineffective transfusions in burn patients with anemia.