bluuebunny/crossref_metadata_2025_split huggingface dataset:
9 Environmental Contamination Reduction Following Standard, Enhanced, and a Novel Cleaning Protocol in a Burn Center
Authors: Khandelwal Anjay , Bigham Michael 
Published: March 2022

Abstract

Introduction
Burn patients are extremely vulnerable to hospital acquired infections, some of which may originate from environmental surfaces. Enhanced cleaning practices of surfaces varies from hospital to hospital. In a burn unit, patients are frequently exposed to multiple environments including the patient room, hydrotherapy and treatment rooms (treatment spaces), and the operating room. We sought to evaluate the efficacy of current protocols, including standard cleaning (SC) and cleaning with ultraviolet light application (C+UV) in the patient rooms and treatment spaces, and compare to a novel Hybrid Hydrogen Peroxide (HHP) fogging system in the patient rooms.

Methods
This study was conducted at a regional 12-bed verified adult and pediatric burn center that functions as an intensive care unit and step-down unit, where patients stay during their entire admission. Data from December 2020 to June 2021 was collected from rooms following 17 patient discharges with a minimum of a 2-week hospital stay. Data was collected from 5 preset locations in the patient rooms following either SC or C+UV and after HHP fogging. Baseline data was also collected from 20 preset locations in the treatment spaces following SC and C+UV. Quantitative and qualitative counts (aerobic colony county [ACC], adenosine triphosphate [ATP]), hydrogen peroxide chemical indicators (CIs) and bacterial spore biological indicators (G. stearothermophilus 1x106 spores) were measured.

Results
No statistically significant difference between SC and C+UV was seen (mean ACC 7.16 and 6.35 respectively; p=0.186). ACC levels were reduced following HHP fogging demonstrating a 98% improvement over SC and C+UV (mean ACC 0.14; p&lt; 0.0001). ATP demonstrated an 88% reduction after HHP fog without manual cleaning. Biological indicators confirmed a 1x106 reduction of bacterial spores, and CIs verified a thorough migration of HHP fog throughout the patient room. Baseline sampling of the treatment spaces following SC and C+UV resulted in a range of 0-70 ACC over 38 swabbed locations, consistent with ACC levels measured in patient rooms (range 0-153). An industry-known location for high bioburden, one sink backsplash swabbed on two separate occasions resulted in &gt;5,700 ACC.

Conclusions
In patient rooms, HHP fogging resulted in a significant reduction in ACC compared to current protocols of SC and C+UV. Baseline sampling of the treatment spaces resulted in ACC levels similar or greater in range to those seen in the patient room, indicating a similar reduction in bioburden levels could be achieved through implementation of HHP fogging. The efficacy and feasibility of HHP fogging in a patient room setting within a burn unit suggests that a protocol for the use of HHP fogging for treatment spaces will likewise be beneficial.
16 Association of Frailty and Comorbidities with Burn Outcomes: A Multicenter Study
Authors: Wallace David L , Wall Joyce E , Man Angela , Heard Jason , Allabadi Najib M , Jeschke Marc G , Savetamal Alisa , Schulz John T , Skipton Romanowski Kathleen S 
Published: March 2022

Abstract

Introduction
Previous work has demonstrated the association of increased frailty and mortality in burn patients, but the impact of specific co-morbidities and frailty on burn patients’ short term outcomes has not been explored. The purpose of this study was to determine the relationship of frailty and patient comorbidities on in-hospital mortality and length of stay (LOS).

Methods
A retrospective chart review of all acutely injured burn patients admitted from January 2016 - December 2017 at 3 US ABA verified burn centers was conducted. Demographics and all comorbidities included in the burn database were collected. The modified frailty index-11 score (MFI) was calculated for each patient. Descriptive statistics, univariate and multivariate analysis were completed to determine the relationship between frailty and comorbidities with mortality, LOS, and LOS/% Total Body Surface Area (%TBSA).

Results
1615 patients were included. Mean age was 45.9 + 17.7 years and 1145 (70.9%) were male. Mean %TBSA was 9.6%+14.2% and mean MFI was 0.43 + 0.74. The mean LOS was 12.3 days + 21.1. A total of 1542 (95.5%) patients survived to discharge. The most common co-morbidities present on admission were: smoking (336, 22.7%), hypertension (HTN, 313, 19.4%), drug dependence (247, 15.3), diabetes (DM, 175, 10.8%), alcoholism (171,10.6%), major psychiatric illness (MPI, 169,10.5%), heart failure (CHF, 23, 1.4%), obesity (7, 4.3%), and respiratory disease (RD, 136, 8.4%). Multivariate logistic regression revealed that RD (OR 3.6, 95%CI 1.4-9.4), age (OR 1.1, 95%CI 1.06-1.1), and %TBSA (OR 1.1, 95%CI 1.1-1.17) were independently predictive of mortality. Multiple linear regression demonstrated patients without alcoholism (β -3.9 95% CI -5.7- -2.1), MPI (β -3.8 95% CI -4.9- -3.0), drug dependence (β -3.9 95% CI -5.7- -2.1), and DM (β -2.0 95% CI -5.7- -2.8) had shorter LOS. Though MFI, heart failure, DM, MPI, alcoholism, and HTN, were all significant for LOS/%TBSA in univariate analysis, they were NOT significant in the multivariate linear regression model.

Conclusions
MFI does not independently contribute to mortality or LOS when accounting for other patient co-morbidities. Respiratory disease on admission is associated with mortality, and major psychiatric illness and drug dependence increase LOS. This information will be used to develop interventions for these groups in order to improve mortality, and decrease LOS.
20 Autologous Meshed Split Thickness Graft Healing in Interstice versus Grafted Sites: A Histological Characterization
Authors: Oliver Mary A , Carney Bonnie C , Keyloun John W , Jimenez Lesle M , Moffatt Lauren T , Shupp Jeffrey W 
Published: March 2022

Abstract

Introduction
Autologous skin grafting is a common technique used in the treatment of full thickness (FT) wounds to aid in healing, wound closure, and reducing the likelihood of developing hypertrophic scarring. Meshed split thickness skin grafts (mSTSG) which contain portions of the dermis and epidermis are the gold standard for the treatment of FT wounds because they allow for expansion of skin taken from a relatively small donor site. It has largely been hypothesized that in mSTSG skin progenitor cells migrate from the edges of healthy donor tissue to aid in healing the interstices created by meshing. For this reason, meshed wound healing is not homogenous as interstice and meshed sites display distinct healing characteristics. This study aims to characterize the differences between interstice and grafted site healing.

Methods
Wound healing was evaluated in vivo using Duroc pigs. In this model, 4 animals had 10.16 cm by 10.16 cm full-thickness burns created on bilateral flanks for a total of 12 wounds. On day 2, the burns were excised down to subcutaneous tissue, mSTSG was harvested, meshed 4:1, and applied to the prepared wound beds. Wounds were photographed and sampled on days 5, 9 and, 15. Punch biopsies from either the grafted area or interstice area were taken at each time point, processed, and imaged. Images were used to quantify epidermal and dermal thickness, cellularity, and rete ridges.

Results
Epidermal thickness at day 5 in interstices was significantly thinner than in graft (1.73±4.33µm vs. 75.7±66.1µm, p&lt; 0.05). By day 9, interstice epidermal thickness was comparable to graft thickness (194.9±157.7µm vs. 199.5±117.7µm). On the other hand, dermal thickness was elevated in the interstice at days 9 (1850.4±642.0µm vs. 1277.6±652.0µm, p&lt; 0.05) and 15 (2469.9±626.14µm vs. 1660.7±674.6µm, p&lt; 0.01) to a significant degree. Cellularity was greater at all time points in the interstice compared to the grafted sites. Similarly, rete ridge ratios (RRR) were significantly greater in the grafted areas at day 5 (0.0±0.0µm v.s. 1.0±0.7µm, p&lt; 0.01) and day 9 (1.32±1.2µm vs. 1.9±0.45µm, p&lt; 0.05).

Conclusions
These data show that within a grafted burn wound, healing is a dynamic and heterogenous process when looking at interstice and graft sites, respectively. Grafted sites were thinner throughout, showed decreased inflammatory cell infiltrate, and exhibited higher RRR. Thicker tissue layers and upregulated cellularity in interstices point to a wound healing trajectory that is slower than grafted sites, even by the time wounds are fully re-epithelized.
38 Utilizing an Implementation Science Framework to Design a Burn Resuscitation Bundle in a Resource-limited Setting
Authors: Mehta Kajal , Lee Joohee , Mesic Aldina , Yadav Manish K , Shrestha Raslina , Poudel Kiran , Gyawali Prakriti , Pham Tam N , Rai Shankar , Stewart Barclay T , Nakarmi Kiran K 
Published: March 2022

Abstract

Introduction
Protocolized burn resuscitation algorithms with hourly, closed loop feedback, have reduced instances of over- and under-resuscitation and improved outcomes in high income countries. However, a “know-do” gap exists as this practice has yet to be adopted in many low- and middle-income countries (LMIC). We aimed to describe the change management process of the development and implementation of a contextually driven protocolized burn resuscitation bundle at a tertiary burn center in an LMIC using an implementation science framework.

Methods
We applied strategies from the Expert Recommendations for Implementing Change (ERIC) for the design and implementation of a burn resuscitation bundle at a major burn center in an LMIC, over a 9-month period. Semi-structured focus group discussions (FGD) were conducted with stakeholders to understand facilitators and barriers to developing and using the protocol, with iterative feedback used to inform and adjust the protocol and documentation tools. Responses were analyzed using content analysis and particularly unique and useful responses were highlighted.

Results
Stakeholders identified resource constraint-related concerns about the feasibility of an hourly IV resuscitation protocol and reached consensus on performing 2-hourly assessments and fluid adjustments. Corresponding documentation tools were developed and iteratively adjusted. Several initial barriers to adoption and institutionalization were encountered. ERIC strategies used to promote intervention uptake included simplification and visualization of the protocol, identification of a project champion, development of educational materials for multiple cadres (e.g., nurses, physicians, health assistants), use of chain of command to enable change and accountability, utilizing institutional branding and ultimately obtaining endorsement by the center’s leadership (Table 1). Post-implementation FGD with stakeholders revealed high levels of acceptance, utilization and adherence of the protocol bundle, with occasional opportunities for improvement identified in protocol completeness and accuracy.

Conclusions
Adoption of change in clinical resuscitation practice in a resource-constrained setting required a contextually driven, multi-faceted approach led by a team of change champions and leaders. The ERIC framework allowed for an iterative approach to prioritize stakeholder engagement and feedback, in order to implement a protocolized IV resuscitation bundle in a LMIC.
42 The Overt Pulmonary and Systemic Pro-inflammatory Response After Burn and Inhalation Injury Is Mtor Dependent
Authors: Hall Hannah R , Mahung Cressida , Seim Roland F , King Booker , Wallet Shannon , Maile Robert 
Published: March 2022

Abstract

Introduction
Severe burn injury can lead to local and systemic activation of the innate immune system which can cause a dysfunctional and overt pro-inflammatory response, resulting in inflammatory complications and organ dysfunction. If there is an inhalation injury concomitant with burn, patients have a 3.6 times higher mortality rate and greater than 70% chance of developing secondary respiratory complications. Previous work has shown that the Mechanistic/ Mammalian Target of Rapamycin (mTOR) pathway is involved in signaling neutrophil activity in burn patients. Antagonists of mTOR stimulation represent possible immunomodulatory therapies. However, it is unclear if mTOR plays a role in the pulmonary distress seen after combined burn and smoke inhalation (B+I) injury. The goals of this study were to 1) characterize a novel mouse model of combined B+I injury and 2) investigate the role of mTOR in the pro-inflammatory response after B+I injury.

Methods
We built upon our pre-established 20% total body surface area cutaneous burn mouse model by adding smoke inhalation injury and treating mice with rapamycin, a mTOR-specific inhibitor. In brief, mice were anesthetized before receiving controlled B+I, burn only, or sham injury. After resuscitation, they were given morphinated water for 24 hours before euthanasia and tissue collection. RNA and whole cells were extracted from lung and spleen tissue for analysis by Nanostring and Flow Cytometry, respectively. Fluid within the lung (bronchoalveolar lavage, BAL) and peripheral blood plasma were collected for pro-inflammatory cytokine quantification via magnetic bead multiplex assays.

Results
Wildtype female C57BL/6 mice that underwent B+I injury exhibited elevated levels of protein, macrophages, and neutrophils in the lung cavity compared to burn alone. In addition, 29 genes were significantly differentially expressed in the lung tissue after B+I, suggesting that inhalation elicits a unique response when compared to burn alone. In the peripheral blood, B+I mice have a &gt;4 fold increase in IL6 and 3 fold increase in MCP-1 pro-inflammatory cytokine levels. When we examined the role of mTOR in B+I injury, we found that pre-emptive rapamycin treatment leads to a reduction in peripheral blood pro-inflammatory cytokine levels, namely MCP1, TNFa, IL10, and IL2, and an increase in pro-inflammatory cytokine IL2 in the lung cavity. Rapamycin significantly affected expression levels of 46 genes in the lung and 36 genes in the spleen, indicating an mTOR-dependent response to inhalation injury.

Conclusions
In conclusion, these data describe a valuable mouse model of B+I with inhalation-specific immune phenotypes and implicate mTOR in the inhalation-induced hyper pro-inflammatory response.
49 Bromelain Based Enzymatic Debridement of Pediatric Deep Burns: Top Line Results of a Multicenter RCT
Authors: Shoham Yaron , Narayan Ravi P , Monstrey Stan , Hoeksema Henk , Lewis Giavonni M , Jha Manoj Kumar , Larson Shawn D , Kravtsov Oleksii , Hanganu Elena M , Gozar Horea G , Pham Tam N , Singer Adam , Sheridan Robert L , Glat Paul M , Sander Frank , Bhavsar Dhaval , Wibbenmeyer Lucy 
Published: March 2022

Abstract

Introduction
Bromelain based debridement (BBD) of deep burns with a concentrate of proteolytic enzymes enriched in Bromelain is approved for use in adults in several regions worldwide. Children are a large part of the patient population in many burn centers around the world. Clinical trial experience and off label reports point to BBD safety and efficacy in children as well. The aim of this study was to further assess the safety and efficacy of BBD in children, in efforts to support regulatory approval for the use of BBD in children.

Methods
One hundred and forty five children aged 0-18 years old suffering from deep thermal burns between 1-30% TBSA were enrolled in a multicenter, multinational, open label, randomized, controlled phase III study. Seventy two children were randomized to eschar removal with BBD and 73 children to standard of care (SOC) surgical and/or non-surgical eschar removal methods, at the investigators' discretion. Patients who did not achieve complete eschar removal after BBD application were rescued with SOC eschar removal methods. Wound care after achieving complete eschar removal was according to routine methods, at the investigators' discretion. Patients are currently in stages of long term follow-up, planned for a duration of &gt;2 years. This abstract reports the top line results of the study including the first year of follow-up.

Results
Baseline characteristics were similar between the arms. The median age was 3.4 years in the BBD arm and 3.9 years in the SOC arm. The average burn area was 7.0±4.9 %TBSA in the BBD arm and 6.2±4.8 %TBSA in the SOC arm. The study met all 3 primary endpoints: Median time to complete eschar removal was 1 day for BBD and 6 days for SOC (p&lt; 0.001), the percent wound area excised in order to complete eschar removal was 1.5% for BBD and 48% for SOC (p&lt; 0.0001), and the MVSS scores at 12 months were 3.83 for BBD and 4.86 for SOC (non-inferiority endpoint). Secondary endpoints demonstrated 8.3% incidence of surgical excision to complete eschar removal for BBD and 64.4% for SOC (p&lt; 0.0001), mean eschar removal associated blood loss of 32±284ml for BBD and 202±409 for SOC (NS), a 25.9% incidence of autografting in deep partial thickness wounds for BBD and 37.7% for SOC (p=0.054), and a mean percent area of deep partial thickness wound autografting of 15.9±38.6 for BBD and 22.8±43.7 for SOC (NS). Safety endpoints demonstrated a non-inferior time to complete wound closure (median 32 days for BBD, 34 days for SOC) and no significant safety issues were demonstrated during the study.

Conclusions
BBD was shown to be a safe and effective debridement agent in pediatric burns.
64 Community Level Disadvantage Negatively Impacts Return to Work After Burn Injury
Authors: Murphy Schachia , McMullen Kara , Carrougher Gretchen J , Mason Stephanie A , Carter Damien W , Stewart Barclay T , Thompson Callie M , Suman-Vejas Oscar E 
Published: March 2022

Abstract

Introduction
The loss of income from injury, additional health care expenses, and inability to return work can lead to unsatisfactory outcomes. Community level disadvantage (e.g., low high school completion, low home ownership, low income) are more common among minority groups. We hypothesized community level disadvantage would negatively impact the ability to return to work after burn injury. This could serve to identify patients who need focused social, vocational, and financial support during rehabilitation.

Methods
Data from adult participants in a large multicenter database from 1998-2021 were linked by zip-code to three multi-domain community level-indices: i) Distressed Communities Index, ii) Social Vulnerabilities Index (SVI), iii) Social Deprivation Index (SDI). Cohort characteristics, the distribution of each index within cohort, and days to return to work were described. Fit and strength of association between the indices and return to work was assessed with multi-level logistic regression models. A non-responder analysis examining demographic and clinical differences between was performed using Chi-square tests and Wilcoxon rank sum tests to understand potential bias in the findings.

Results
A total of 1960 participants provided both zip code and employment data 6 months after injury. 75% of participants were male. Mean age was 39. Race/Ethnicity Data: 81.4% identified as White, 11% Black, and 7% as “other” race; 84% of the participants as non-Hispanic or Latino. Median burn size was 20% TBSA (IQR 0.1-95.0), and length of hospitalization was 30 days (IQR 0-379). Of the community indices tested, both DCI and SVI were associated with return to work with DCI having the strongest association with return to work after injury, irrespective of indices. However, when DCI and SVI were included in the model to represent community disadvantage, the impact of race on return to work was less. Participants who did not provide employment information were younger, sustained larger burn sizes, and had longer LOS compared to those who did.

Conclusions
DCI and SVI are associated with return to work after burn injury and can be used to focus limited social, vocational, and financial services. Minoritized participants were less likely to return to work but they live in communities with greater disadvantage (e.g. fewer employment opportunities), which highlights the public health impacts of structural racism.
68 The Association Between Body Mass Index and Physical Function in Adult Burn Survivors
Authors: Palackic Alen , Rontoyanni Victoria G , Branski Ludwik K , Duggan Robert P , Schneider Jeffrey C , Ryan Colleen M , Kowalske Karen J , Gibran Nicole S , Stewart Barclay T , Wolf Steven E , Suman-Vejas Oscar E , Herndon David 
Published: March 2022

Abstract

Introduction
An area of rehabilitation research in burns is the impact of co-morbidities. Obesity is one of these, is an increasing public health concern, and its role remains controversial regarding burn injury and physical recovery. Our aim was to evaluate associations between body mass index (BMI) as a measure of obesity, at discharge and self-reported physical function (PF) during recovery of adult burn survivors.

Methods
This study included data that was collected by four American Burn Association-verified burn centers, which contribute to the Burn Model System National Database project. The data included BMI obtained at hospital discharge and self-reported Patient-Reported Outcomes Measurement Information System (PROMIS)-29 PF-mobility and upper extremity scores assessed at 6-, 12-, and 24-months after burn. Mixed linear models for repeated measures and regression models were used to assess associations between BMI and PROMIS-29 PF scores over time. Values are expressed as means ± SD. Significance was set at p&lt; 0.05.

Results
A total of 502 adult patients aged 47 ± 16 years were included, with mean total body surface area burned (TBSA) of 17 ± 18 % (range; 1.0-88%) and mean BMI of 23.1 ± 5.4 kg*m-2 (range; 14.0-64.7 kg*m-2). We found no significant effect at 6 months (beta=-0.045, p= 0.54) nor at 12 months after injury (beta=-0.063, p= 0.44) when adjusted for age, burn size, and sex, however, BMI at discharge had a significant negative effect on self-reported mobility scores 24 months after injury (beta=0.218, p=&lt; 0.05).

Conclusions
Increased weight (i.e. BMI) at discharge was negatively associated with PF during recovery. Benefiting from a large sample size, our analysis suggests that long term recovery and restoration of PF in adult burn survivors is compromized by excess body weight.