bluuebunny/crossref_metadata_2025_split huggingface dataset:
47 Burn Injury Assessment Study (BIAS): Is There Room To Improve?
Authors: Carter Jeffrey , Phelan Herbert , Friedstat John , Hickerson William , Holmes James , Hwang James , Kahn Steven , Savetamal Alisa , Shupp Jeffrey 
Published: May 2023

Abstract

Introduction
The treatment of burn injured patients requires accurate wound assessment to determine appropriate interventions. Clinical assessment of burn depth, even by experts in the field, has an accuracy of only 60–80%. The purpose of this study is to estimate the performance of burn wound assessment by burn care professionals from still images.

Methods
This was an IRB-approved prospective cohort study in which burn care providers used a tablet-based digital interface to answer a 10-item questionnaire and to identify non-healing burn wounds from 5 patients scenarios. Each wound was evaluated using a polygon software interface to mark non-healing regions within the wound. Each wound had a ground truth determined by a consensus panel of study investigators using still photograph at 21-days post-injury to discern healing and non-healing regions. A power analysis and sample size of 100 participants produced a two-sided 95% confidence interval with a width equal to 0.20 when the sample proportion is 0.60. Continuous variables were analyzed by mean, standard deviations, median and quartiles while categorical data was analyzed as exact number and percentage. Burn wound assessment performance metrics for the providers were calculated for the whole cohort and then for subgroups using point estimate at a pixel level. Accuracy, sensitivity, specificity, area positive predictive value (APPV), and area negative predictive value (ANPV) were calculated from the ground truth and participants selected regions of non-healing wounds.

Results
One hundred fifty-six healthcare providers enrolled (50 physicians, 14 APPs, 63 nurses, 24 therapists, and 5 paramedics) with 9.96 ± 9.49 mean years of experience and 70% employed at a verified burn center. All five regions were represented in the analysis (Eastern Great Lakes (4%), Midwestern (6.5%), Northeastern (22%), Southern (53.5%), and Western (14%). 29.3% of the participants selected “schedule for surgery” when reviewing images of wounds that healed without surgery. 28.7% of the participants selected, “local wound care no surgery needed or, “local wound care, reassess in 7+ days for possible surgery.” Performance measures were not associated with years of experience. Overall performance is available in Table 1.

Conclusions
Improving burn wound assessment performance could improve our use of limited resources in burn care by optimizing patient transfers/treatments and avoiding unnecessary surgeries. Our study expands upon prior work in the field and demonstrates that burn wound assessment has significant room for improvement. These findings open the proverbial door for diagnostic devices found in other fields of medicine and our partnership with emergency room providers to advance burn care.

Applicability of Research to Practice
More accurate wound assessment will lead to improved treatment and triage by EM and Burn practitioners.
48 Iatrogenic Vitamin A Toxicity Leading to Hypervitaminosis and Hypercalcemia: A Case Series and Cautionary Tale
Authors: Hall Alexandria , King Jessie , Tobias Laura , Stewart Barclay , Rhodes Lori 
Published: May 2023

Abstract

Introduction
Patients with major burn injuries receive micro-nutrient supplementation to promote wound healing and mitigate hypermetabolic complications. Vitamin A promotes epithelialization, angiogenesis and collagen synthesis and is included in ‘trauma vitamin’ bundles. As a fat-soluble vitamin, prolonged supplementation can lead to cumulative toxicity. Hypercalcemia can cause polyuria, ECG changes, and organ dysfunction. We report a case series of potential iatrogenic vitamin A toxicity among people with major burn injury.

Methods
Concern for vitamin A toxicity was raised by pharmacy and endocrinology after two patients were found with severe hypercalcemia and a consistent toxidrome. In response, we performed a chart review of adult patients with ≥20% TBSA who received vitamin A 25,000 units thrice weekly for at &gt;2 weeks during March 2021 – July 2022. Hypercalcemia was defined as serum calcium concentration &gt;10.4 mg/dL ( &gt;2.60 mmol/L) or ionized serum calcium &gt;5.2 mg/dL ( &gt;1.30 mmol/L). Kruskal-Wallis test examined differences in median values.

Results
A total of 67 patients met screening criteria with 25 included in the series. Nine patients (36%) developed hypercalcemia. One patient developed hypercalcemia on day 5 of admission and was excluded. Median days to hypercalcemia was 52 (IQR 39-72). There were no differences in age, burn size, or weight between patients with and without hypercalcemia. Patients with hypercalcemia had significantly longer courses of vitamin A (56 vs 27 days, p=0.03) as well as length of stay (122 vs 63 days, p=0.01). One patient required treatment with a bisphosphonate. All improved with cessation of vitamin A supplementation.

Conclusions
A third of patients who received high-dose vitamin A as per a micronutrient supplementation protocol developed hypercalcemia. Our protocol was changed to limit vitamin A therapy to 21 days. Given that hypercalcemia among hospitalized patients is multifactorial, further evaluation with a larger case-control study is required to determine if high-dose vitamin A is a contributing factor.

Applicability of Research to Practice
Recommended daily allowance of vitamin A is ~3,000 units daily. Given that patients on enteral feedings receive approximately 3,600 units daily, vitamin A supplementation may result in toxicity if provided for &gt;3-5 weeks.
49 Post-Injury Trajectory of Body Mass Index Among Burn Survivors
Authors: Cato Liam , Shepler Lauren J , Kazis Lewis , Schneider Jeffrey , Suman-Vejas Oscar , Stewart Barclay , Kowalske Karen , Ryan Colleen 
Published: May 2023

Abstract

Introduction
Hypermetabolism following a burn injury causes perturbations of key cardiopulmonary and cellular functions which often persist long-term. Patients are advised to increase caloric intake to address this hypermetabolic state. However, potential weight change implications from such blunt strategies are not well studied. We aimed to 1) determine factors associated with weight change from discharge and 2) understand their relationship to other physical and psychosocial measures over time. By doing so, more tailored approaches to healthy weight management could be devised.

Methods
Adult participants that were enrolled in the Burn Model System (BMS) National Database after 2015 were included in the analysis. Weight was collected and BMI calculated during admission and at 0.5, 1, 2, and 5 year follow-ups. Mixed models included repeated measures controlling for correlated error of the outcomes and were used to assess the association of weight change with demographic, injury factors and psychosocial measures over time.

Results
A total of 698 individuals were included in the analysis. Median age was 48 years (IQR 33, 59), 218 participants were female (31.2%), median TBSA injured was 10% (IQR 3, 25), and 388 sustained flame injury (55.6%). Median BMI was 26.75 kg/m2 (IQR 23.67, 31.05). During follow-up, 446 participants (64%) had a median weight gain from admission to last follow-up of 2kg (IQR -2, 6.3). There were significant differences in weight trajectory between BMS centers (p=0.0003), which was included in subsequent models. Sex, marital status, and race were not associated with weight change. Increases in burn size (p&lt; 0.0001) and number of months working after injury (p=0.03) were associated with greater weight, while older age at time of injury (p&lt; 0.0001) was associated weight loss. Greater weight gain was associated with higher PROMIS-29 Physical Function (p=0.002) and Neuro-QOL (p=0.03) scores (meaning better) after one year. PROMIS-29 Sleep Disturbance score was associated with weight change only between years 2-5 of follow-up (p=0.029), with higher sleep disturbance score associated with lower BMI.

Conclusions
Most people living with burn injury experienced a modest weight gain after injury. Weight trajectory was impacted by several demographic factors including age, burn size, and amount time spent working, as well as physical and psychosocial measures (PROMIS-29 Physical Function, Neuro-QOL).

Applicability of Research to Practice
These factors can be used to inform anticipatory guidance, diet recommendations, and exercise programs for people with burn injury. The impact of tracking weight and health goals with patients in the outpatient settings should be more closely examined.
50 Metformin versus Insulin: Glucose Control and Safety in Burn Patients
Authors: Hallman Taylor , Wolf Steven , Golovko Georgiy , Song Juquan , El Ayadi Amina 
Published: May 2023

Abstract

Introduction
Patients suffering from moderate-to-severe burns are known to experience significant metabolic perturbations, such as hyperglycemia, as the result of a systemic hypermetabolic response. Hyperglycemia in these patients is in part due to the development of peripheral insulin resistance. Glycemic control is important, as hyperglycemia in patients with moderate-to-severe burns is associated with increased morbidity and mortality. Insulin and metformin are the first lines of treatment, with previous studies showing metformin to be superior to insulin in reducing burn-induced hyperglycemia. We queried a large multi-institutional national database to investigate whether the use of metformin in burn patients is associated with improved glycemic control and morbidity/mortality outcomes compared to insulin therapy.

Methods
We accessed TriNetX, a global health research network, and queried ICD-10 codes for burn injuries (T20-25, T30-32) across 54 participating health care organizations. We then identified cohorts of patients who were administered either metformin or insulin, but not both, within 1 week of burn. These cohorts were balanced using propensity score matching for age, gender, ethnicity, race, and type 2 diabetes mellitus and subsequently compared for the following outcomes: hyperglycemia (R73), hypoglycemia (E16.1, E16.2), lactic acidosis (E87.2), sepsis (A41), and death.

Results
A total of 16,569 patients were given insulin within 1 week of burn. This patient cohort had a mean age of 54 years, with 60% being male, 67% White, and 19% Black or African American. In contrast, 7,308 patients received metformin within 1 week of burn, with a mean age of 56 years, 55% female, 70% White, and 16% Black or African American. Burn patients who received insulin within 1 week of burn showed a comparative increased risk of 3.009% (p &lt; 0.0001) for the development of hyperglycemia compared to those who were given metformin within 1 week of burn (RR: 3.165, 95% CI: 2.433-4.117). Additionally, burn patients given insulin displayed an increased risk of 2.452% for development of hypoglycemia (p &lt; 0.0001, RR: 4.555, 95% CI: 3.317-6.255), 3.078% for development of lactic acidosis (p &lt; 0.0001, RR: 17.541, 95% CI: 10.003-30.76), 3.67% for development of sepsis (p &lt; 0.0001, RR: 12.106, 95% CI: 7.898-18.557), and 7.422% for death (p &lt; 0.0001, RR: 13.996, 95% CI: 10.212-19.182).

Conclusions
Patients receiving insulin within 1 week of burn showed increased risk of poor glycemic control than those receiving metformin. Morbidity and mortality are also higher in those receiving insulin than those receiving metformin. Additional research is necessary to further understand these findings.

Applicability of Research to Practice
These findings should encourage clinicians to appreciate the importance of glycemic control in burn patients, as well as recognize the importance of choosing the most appropriate pharmacologic agent for glycemic control.
52 Open-Label, Expanded-Access Study of a Bioengineered Allogeneic Cellularized Construct in Adults With Deep Partial-Thickness Burns
Authors: Gibson Angela , Joe Victor , Carson Joshua , Litt Jeff , Carter Jeffrey , Holmes James 
Published: May 2023

Abstract

Introduction
An FDA-approved bioengineered allogeneic cellularized construct (BACC) provides burn surgeons with an alternative treatment for deep partial-thickness (DPT) burns and may reduce the need for autografting. A phase 3b, open-label, single-arm, multicenter, expanded-access study (NCT04123548) evaluated safety and clinical outcomes of BACC treatment in adults with DPT thermal burns containing intact dermal elements.

Methods
Patients aged ≥18 years with 3% to &lt; 50% total body surface area of partial-thickness ± full-thickness thermal burns were enrolled. A single application of up to 1:1 meshed BACC was applied to ≤3 burn areas on the torso or extremities (≤2000 cm2 area of BACC). Patients were followed for 24 weeks. The primary endpoint was count and percentage of patients with treatment-emergent adverse events (TEAEs). Additional endpoints were patients and treatment sites with confirmed wound closure (complete re-epithelialization without drainage for 2 consecutive visits ≥2 weeks apart) of the BACC treatment site without autografting by Week 12; durable wound closure by Week 24; time to wound closure without autografting (determined by Kaplan-Meier estimate); scar evaluation using the Patient and Observer Scar Assessment Scale (POSAS); and patients with wound infection-related events. The sample was not designed or sized to determine efficacy.

Results
Overall, 52 patients were enrolled. Pruritus was the most frequently reported TEAE (n=22 [42.3%]). There were 2 (3.8%) BACC-related TEAEs; both were pruritus and mild in severity. There were 20 serious AEs in 10 (19.2%) patients; none were related to BACC. No patients discontinued the study due to TEAEs. There were 4 (7.7%) deaths (aspiration, myocardial infarction, self-injury, and Gram-negative rod sepsis); none were related to BACC. Wound infection-related events occurred in 5 (9.6%) patients. Overall, 46 (88.5%) patients and 87 (90.6%) BACC-treated wounds did not require autografting. Half of patients achieved wound closure by Week 5. At Weeks 12 and 24, observer and patient total POSAS scores (mean ± SD) were 18.7 ± 8.08 and 18.8 ± 9.84, and 24.5 ± 11.0 and 20.2 ± 12.5, respectively.
Wound closure of the BACC treatment site without autografting

Conclusions
There were no unexpected wound or BACC-related events. The safety of BACC supported its prescribing information. Patients treated with BACC achieved durable wound closure without autografting and thus showed expected clinical benefit in this population. The use of BACC in DPT burns in this study was donor-site sparing.

Applicability of Research to Practice
Treatment with BACC may offer a promising alternative to autografting for DPT burns.
61 Effect of Pre-Existing Hypertension on Cardiovascular Support and Mortality Among Major Burn Patients
Authors: Stephens Trina , Papp Anthony , Papp Bettina , Sheikh-Oleslami Sara , Griesdale Donald , Jain Fagun 
Published: May 2023

Abstract

Introduction
Hypertension (HTN) is the most common comorbidity seen in patients who sustain a major burn. HTN causes increased responsiveness of the autonomic nervous system to stressful stimuli, activation of RAAS, arterial and myocardial hypertrophy, and impaired vasodilation. Changes to these pathways are also seen in response to major burns. Given this common pathophysiology, patients with pre-existing HTN may demonstrate different mortality risk after major burn than those without HTN. The objective of this study is to compare the risk of in-hospital mortality among adult patients with and without pre-existing HTN admitted to the intensive care unit (ICU) with a major burn. In addition, we sought to determine the association of pre-existing HTN with the need for vasoactive agents, fluid resuscitation and urine output in the first 48-hours of ICU admission

Methods
Single-centre, historical cohort study using data from a Burn Registry, Intensive Care Database, and medical chart review. Variables of interest were demographic and injury characteristics, use of vasoactive agents, 12-, 24-, and 48-hour fluid requirements and urine output, and in-hospital mortality. We included adult (≥18 years) patients presenting with ≥20% total body surface area (TBSA) burns who were admitted to the ICU from January 2010 to August 2021. Pre-existing HTN was defined by pharmacy records showing the patient had filled a prescription for an anti-HTN medication within the 12-months prior to their burn. We compared variables of interest by HTN exposure and conducted univariate analysis to assess mortality risk

Results
199 patients met inclusion criteria. Of these, 145 records were complete. The mean (standard deviation, SD) age was 47 (7) years and TBSA was 37 (16) percent. Most patients were males (83.5%) who sustained a flame burn (87.6%) without an inhalation injury (28.5%). Pharmacy records revealed that 28 patients (19.3%) had pre-existing HTN. Mean (SD) 24-hour fluid requirements were 7.1 (5.6) L and 5.2 (3.2) L for HTN and non-HTN patients, respectively (p=0.17). Mean (SD) 24-hour urine output was 1024 (747) mL and 1314 (780) mL for HTN and non-HTN patients, respectively (p=0.12). Sixty-one percent of HTN patients required vasoactive agents in the first 24-hours compared to 46.2% of non-HTN patients (p=0.18). Pre-existing HTN was associated with a 5-fold increase in in-hospital mortality (OR 5.5, CI 2.2-14.0)

Conclusions
Preliminary results suggest differences in fluid requirements, urine output and mortality risk between HTN and non-HTN patients with major burns. An external registry has been queried to identify pharmacy records for the 54 patients with missing data

Applicability of Research to Practice
Identifying differences in mortality risk and need for cardiovascular support among burn patients with HTN changes our approach to counselling and caring for these patients
62 Effect of Glycemic Variability on Infectious Outcomes in Patients with Severe Burn Injuries
Authors: Hill David , Hoang Kristine , Ly Austin , Liu Xiangxia , Velamuri Sai 
Published: May 2023

Abstract

Introduction
Stress-induced hyperglycemia is a common manifestation of severe burn injury, due to increased catecholamines, glucagon, corticosteroids, and cytokines. The primary objective of this study was to evaluate the relationship between different measures of glycemic variability and infectious outcomes in burn patients.

Methods
This retrospective electronic chart review included patients admitted to a single American Burn Association-verified burn
center for the year of 2020. Infectious complication was defined as occurrence of proven infection, autograft loss, or
death. Glycemic variability indices tested include standard deviation, mean amplitude of glycemic excursions, J-index,
and coefficient of variability. Demographics were compared utilizing Fisher’s exact or Mann-Whitney U test, depending
on dichotomy. Logistic regression analysis was utilized to control for revised Baux score. Likelihood ratio test statistic was
utilized to compare strength of association.

Results
Three-hundred and ninety-two patients were admitted during 2020 and screened for inclusion. After applying exclusion
criteria, 112 patients remained in the study group. More than half were excluded for length of stay less than 3 days. Twenty-five
(22%) had at least one infectious complication (21 infections, 3 with graft loss, and 4 deaths). Revised Baux, age,
percent total body surface area burned, history of diabetes, and admission blood glucose were all higher in the group
with an infectious complication. Out of the indices tested, only mean glucose (Odds ratio, 95% confidence interval:
1.024, 1.004-1.045) and J-index (1.044, 1.002-1.087) were significantly associated with higher risk of an infectious
complication. Quantile analysis of mean glucose thresholds indicated &gt; 150 mg/dL to have the strongest association with
infectious complications in burn patients.

Conclusions
Although J-index was significantly associated with infectious complications, mean glucose was also and has a simpler
derivation.

Applicability of Research to Practice
A liberal glucose control strategy should continue to be avoided in patients with burn injuries due to higher risk of infectious complication.
63 Adjunctive Ketamine Reduces the Risk of Developing Chronic Opioid Use in Burn Patients
Authors: Amador Dalton , Obias Isabel , Karam Kathleen , Soudah Chris , Arceneaux Amy , El Ayadi Amina , Song Juquan , Golovko Georgiy , Wolf Steven 
Published: May 2023

Abstract

Introduction
Opioid use for perioperative pain management in burn patients is associated with a high risk of developing chronic opioid use. Ketamine is commonly used as an analgesic adjunct due to its opioid-sparing effects. The purpose of this study is to determine whether analgesia with adjunctive ketamine reduces the risk of developing chronic opioid use in burn patients.

Methods
Burn patients who underwent burn-related surgeries were identified using relevant ICD-10 Codes. Data were collected using the TriNetX Research Network, a national research database providing de-identified patient medical records.
Burn patients undergoing surgical procedures were identified based on their use of opioids alone or in combination with ketamine as adjunctive analgesia. Both groups excluded patients with a prior history of opioid-related and psychiatric disorders to control for potential pre-existing conditions affecting the study outcomes. Outcome analysis included continued opioid use and related psychiatric disorders, including nicotine dependence and anxiety, up to one year after burn injury. Risk ratios for each outcome were then generated using a measure of association analysis through TriNetX.

Results
We identified 107,270 patients across 51 health care organizations who underwent burn-related surgeries within one month after burn injury. Excluded from the study were 3,296 (3.07%) patients who had a prior history of opioid-related and psychiatric disorders. The remaining 103,974 patients were sorted into respective groups that received opioids with ketamine (n = 8,328) and without ketamine (n = 51,413). The two cohorts were balanced using (1:1) propensity score matching for age, sex, race, ethnicity, and burn surface area.
Patients without ketamine had a higher risk of continuing opioid use (risk ratio [RR], 1.14, p &lt; 0.001), developing nicotine dependence ([RR], 1.32, p &lt; 0.001), and developing anxiety disorders ([RR], 1.21, p = 0.007) at least one year after burn injury.

Conclusions
Burn patients whose pain management included adjunctive ketamine ceased opioid use sooner and demonstrated a lesser risk of developing various psychiatric disorders associated with chronic opioid use.

Applicability of Research to Practice
This study supports the use of adjunctive ketamine as part of a multimodal approach to pain management in burn patients in order to minimize the risk of chronic opioid use.