bluuebunny/crossref_metadata_2025_split huggingface dataset:
10 The Impact of Insurance Disparities on Long-term Burn Outcomes: A Burn Model System Investigation
Authors: Castillo-Angeles Manuel , Shepler Lauren J , Carrougher Gretchen J , Gibran Nicole S , Stewart Barclay T , Wolf Steven E , Kowalske Karen J , Ryan Colleen M , Schneider Jeffrey C , Mehta Anupama 
Published: March 2022

Abstract

Introduction
Access to healthcare and insurance coverage are associated with quality of life, morbidity, and mortality outcomes. However, most studies have only focused on same-admission and short-term outcomes due to the lack of national longitudinal data and there is limited data on this topic in the burn literature. Our aim was to determine the effect of insurance status on long-term outcomes in a national sample of burn patients.

Methods
This is a retrospective study using the longitudinal Burn Model System National Database from January 2015 to April 2021. The inclusion criteria were all adult patients admitted for burn injury from participating sites. Main outcomes were the physical (PCS) and mental (MCS) health component summary scores of the Veterans RAND 12 (VR-12) score at 6, 12, and 24 months after injury. Multivariable regression was used to examine the association between insurance status and the outcomes, adjusting for demographics (i.e., age, gender, race/ethnicity) and burn injury severity.

Results
A total of 3,698 burn patients were included. Mean age was 43.39 (SD 15.84) years, 72% were male and 76% were white. Most patients had private/commercial insurance (56.37%), followed by Medicare (14.42%) and Medicaid (13.18%). The remaining 16% were uninsured patients (self-pay or philanthropy). Mean PCS scores were 43.64 (SD 10.87), 45.31 (SD 11.04) and 46.45 (SD 10.65) and Mean MCS scores were 47.80 (SD 12.35), 48.18 (SD 12.30) and 48.44 (SD 12.18) at 6, 12 and 24 months, respectively. In adjusted analyses, Medicaid insurance was associated with worse MCS at 6 months (Coefficient -3.90, p=0.001), and worse PCS at 12 and 24 months (Coefficient -3.09, p=0.004 and Coefficient -4.18, p&lt; 0.001, respectively), compared to uninsured status. Medicare insurance was associated with worse PCS scores at 24 months (Coefficient -3.07, p=0.013).

Conclusions
Having Medicaid and Medicare insurance was significantly associated with a lower health-related quality of life at long-term follow up, even after adjusting for demographics and burn injury severity. Further studies need to focus on analyzing the reasons for these disparities and developing strategies to improve the quality of life of this subpopulation.
13 Statewide Prehospital Routing of Burn Injuries Reduces Patient Length of Stay
Authors: Kearns Randy D , Short Tracee , Barrios Joseph , Sittig Kevin , Hargrove Paige B , Hector Chris W , Carter Jeffrey E 
Published: March 2022

Abstract

Introduction
In the U.S., traumatic injuries are the leading cause of death before age 45 and have a significantly lower mortality if routed to a verified trauma center. Burn injuries are included in trauma statistics and represent 1.1 million injured people annually seeking medical assistance. Routing of burn injuries to ABA-recognized burn centers has yet to be assessed as it has in trauma injury. Our goal was to examine the impact of prehospital routing of burn injuries on hospital length of stay, mortality, and potential costs of care through a statewide care coordination center, the Louisiana Emergency Response Network.

Methods
Our study is a retrospective statewide analysis of burn injuries from 01/01/2017 thru 12/31/2019 using the Louisiana Hospital Inpatient Discharge Database. Routing of burn patients was implemented in 2018 using the ABA burn referral criteria. Data included: total admissions with primary burn diagnosis, region, discharge status, length of stay, and raw mortality by region and state. Descriptive and comparative statistics were performed to assess the impact of routing of burn injured patients. Cost analysis was performed using Louisiana Medicaid per diem rates from 2021 at $1,907.92/day.

Results
1,288 patients were treated in Louisiana during the study period with 855 post-routing and 433 pre-routing. The mean length of stay was reduced from 11.84 days in 2017 to 8.82 days in 2018 (p value=0.0988) with a potential savings of 761 inpatient care days or $2.17 million. Overall mortality across the state was unchanged except in the highest volume region where it dropped from 7.9% in 2017 to 3.6% in 2019 (54%).

Conclusions
Burn injuries meeting ABA referral criteria are a form of time-sensitive trauma. This study marks the first analysis pre and post implementation of routing for burn injuries by a statewide care coordination center. Our study demonstrates improvement in length of stay and mortality but a continued need to examine other contributing factors such as severity of injury and concomitant trauma.
18 Comparison of Topical Agents for Eschar Removal in Porcine Model: Bromelain-enriched vs. Traditional Collagenase Agents
Authors: Singer Adam , Grandfield Samuel , Goradia Eshani , Shah Kunal , Zhang Nigel , McClain Steve 
Published: March 2022

Abstract

Introduction
Surgical excision and grafting of deep partial thickness (DPT) and full thickness (FT) burns is a cornerstone of modern burn wound care. Use of commercially available topical enzymatic agents has been limited due to slower and less complete eschar removal than surgical excision. Using a porcine model of DPT and FT burns, we compared the eschar removal efficacy of a bromelain-enriched enzymatic agent derived from the stems of pineapple plants and a commercially available collagenase.

Methods
Under an approved animal welfare committee protocol, we created 10 DPT and 10 FT burns measuring 2.5 by 2.5 cm on each of four anesthetized Yorkshire pigs weighing 30 kg using a preheated aluminum bar applied to the dorsum and flanks of the animals. For DPT burns, the bar was preheated to 80ºC and applied for 20 seconds with a pressure of 2 kg. For FT burns, the bar was preheated to 100ºC and applied for 30 seconds. Eschar removal was initiated 24-hours later. Two pigs each were randomly assigned to collagenase or the bromelain-enriched agent. The bromelain-enriched agent was applied topically once on day 1 for a period of 4 hours followed by a 2-hour soaking period with normal saline. The collagenase was applied topically daily as per manufacturer instructions until complete removal of the eschar or for up to 14 days. The primary outcome was the percentage of burns with complete eschar removal assessed by a masked observer at 1, 10 and 14 days after application.

Results
A total of 40 FT and 40 DPT burns were created on the four pigs. Regarding FT burns, all bromelain treated burns experienced complete removal of eschar on day 1 after the single 4-hour application. In contrast, none of the collagenase treated FT burns experienced complete removal of eschar after 14 days of treatment. At 10 days, 30% of collagenase treated burns had &lt; 50% removed eschar; by day 14, 40% had &gt;50% removed eschar and 15% had &lt; 50% eschar removed. Regarding DPT burns, all bromelain treated burns had complete eschar removal after the single 4 hour application. In contrast, none of the collagenase treated burns experienced complete removal of eschar after 10 days; by day 14, 35% had complete eschar removal. At day 10, 10% of collagenase treated burns had &gt;50% eschar removed and 75% had &lt; 50% eschar removed; by day 14, 30% had &gt; 50% eschar removed and 35% had &lt; 50% eschar removed. There were no wound infections or any other adverse events noted.

Conclusions
Topical treatment of DPT and FT porcine burns with a single 4-hour application of a bromelain-enriched enzyme resulted in complete eschar removal of all burns. In contrast, after 14 daily topical applications of the collagenase, none of the FT burns experienced complete removal of the eschar and in 35% of the DPT burns, eschar removal was complete.
21 Decreasing Preparation Time of Full-thickness Engineered Constructs: Seeding Dermal Allografts with Non-cultured Keratinocytes
Authors: Gallentine Summer , Powell Heather 
Published: March 2022

Abstract

Introduction
Early wound closure reduces risk of infection and fluid loss, which can reduce mortality and decrease length of hospital stay. The most common challenge associated with rapid wound closure in patients with large, full-thickness (FT) burns is lack of available donor skin. Tissue engineering can generate significant amounts of tissue for grafting but requires specialized facilities and up to three weeks of culture, substantially increasing time to closure.
Off-the-shelf technologies that do not require ex vivo culture of cells represent a major advance in wound care. Point-of-care cell spray technology isolated using an autologous cell harvesting device (ACHD) allows for immediate application of a cell suspension to the wound bed, eliminating specialized laboratory equipment and culture of skin cells. The goal of this project was to assess the ability of freshly isolated skin cells harvested using ACHD or traditional laboratory techniques to regenerate epithelium on engineered dermal tissue, in an effort to decrease time required for preparation of FT engineered skin.

Methods
Dermal allografts were made by seeding collagen scaffolds with human dermal fibroblasts. Human surgical discard tissue was collected with IRB approval. Split-thickness skin (0.008”) was harvested from the discard tissue and cells were isolated using ACHD or via standard laboratory procedures following epidermal separation. Cell suspensions were seeded on the dermal allografts and cell populations were assessed histologically using H&E and Fontana-Masson’s, and via immunohistochemistry for Ki67, ColIV, ColVII, keratin 15, and involucrin. Advanced phenotyping of the cell suspension isolated using ACHD was assessed using flow cytometry.

Results
Isolation of cells using ACHD required 8-fold less preparation time and resulted in a different ratio of cell constituents. ACHD yielded suspensions comprised predominantly of keratinocytes (60-75%), fibroblasts (25-40%), and melanocytes (1-3%). Advanced phenotyping indicates subpopulations of keratinocytes including epidermal stem cells, activated keratinocytes, and proliferating keratinocytes. The standard laboratory protocol resulted in a keratinocyte suspension (96-99%) with melanocytes (1-3%) and no fibroblasts. Both cell suspensions were capable of epidermal regeneration with greater pigment and slightly higher numbers of proliferative cells and epidermal stem cells with the ACHD.

Conclusions
The results suggest non-cultured cell sprays have the potential to regenerate bioengineered dermal allografts in the absence of a split-thickness skin graft. Additionally, ACHD offers a significant time advantage to laboratory-based procedures in the preparation of cell-spray.
27 Pain Medication Use at Follow up Is Associated with Long-term Outcomes
Authors: Kelter Brian M , Shepler Lauren J , Stewart Barclay T , Wolf Steven E , Mandell Samuel P , Kazis Lewis E , Ryan Colleen M , Schneider Jeffrey C 
Published: March 2022

Abstract

Introduction
Use of prescription pain medication after burn injury is commonly required. However, little is known about long-term pain medication use and its association with outcomes. Therefore, the purpose of this study is to assess patterns of prescription pain medication use after discharge and the association between these medications and quality of life outcomes.

Methods
Data from the Burn Model System National Longitudinal Database (2015-2021) were analyzed. Pain medication use was assessed at pre-injury (recall at discharge), discharge (medical record) and follow-up (self-report at 6, 12, and 24 months after injury). Outcome measures included: VR-12 Physical and Mental Component Summary scores (PCS and MCS), Community Integration Questionnaire (CIQ), Posttraumatic Stress Disorder Checklist (PCL), Satisfaction with Life Scale (SWLS), and NeuroQOL Stigma. The population was divided into two groups, those taking and not taking prescription pain medications at one year. Regression analyses examined associations between prescription pain medication use and outcomes at 12 months, controlling for age, gender, race, ethnicity and burn size.

Results
Of the 645 participants, 15% reported prescription pain medication use prior to their burn. At discharge, 81% reported use of an opioid and 46% reported use of a neuropathic pain medication. At 12 months, 32% of individuals indicated prescription pain medication use. The pain medication group exhibited larger burn size (24.0% vs 15.2%) and longer hospital stays (40.4 vs 25.0 days) than the non-pain medication group (p&lt; 0.0001 for all). Additionally, 25% of individuals who reported pre-injury pain medication use also reported use at 12 months. Regression analyses demonstrated that pain medication use was associated with worse physical health (PCS: coefficient 8.69, p&lt; 0.0001) mental health (MCS: 6.31, p&lt; 0.0001), stigma (NeuroQOL Stigma: 3.91, p&lt; 0.0001), and satisfaction with life (SWLS: -3.66, p&lt; 0.0001) at one year. Additionally, pain medication use was associated with 45% decreased odds of being employed (coefficient 0.55, p=0.029) and approximately 3 times greater odds of having post-traumatic stress disorder at 12 months (coefficient 3.25, p&lt; 0.0001).

Conclusions
There are significant associations between prescription pain medication use and worse physical, mental and employment outcomes at twelve months. This information may be used to trigger screening and manage long-term recovery outcomes.
28 Risk Factors and Outcomes of Opioid Dependence After Burn Injury: A Single Center Study
Authors: Walters Elliot , Wolf Steven E 
Published: March 2022

Abstract

Introduction
Patients with severe burns often have a prolonged recovery course and frequently opioid pain medications. Several studies showed patients who receive frequent and high doses of opioid medications are at elevated risk of developing opioid dependence. Risk factors for opioid dependence have been established in several fields, including in trauma patients, however opioid dependence within the burn population has not been well studied. In this study we identify risk factors and outcomes for burned patients with opioid dependence.

Methods
We performed a review of a deidentified database that covers our institution comprising over 1.9 million patients. ICD-10 codes were used to identify those with burns. We identified 9150 patients who received treatment for a burn injury between January 1, 2010 and December 31, 2020. From this cohort 130 patients (1.4%) developed documented opioid dependence. Patients from each cohort were balanced by propensity score matching. The database was then examined to determine treatment type and concomitant diagnoses.

Results
Prior to matching we found a significant increase in mortality, chronic pain, non-opioid substance abuse, depression, and use of opioid and non-opioid medication (p&lt; 0.05) for those with opioid dependence. After propensity score matching, we found no significant increase in mortality or depression (p &gt;0.05). Chronic pain and non-opioid substance abuse remained elevated (OR 2.7, CI 1.6, 4.4; OR 2.4, CI 1.3, 4.5, p&lt; 0.05, respectively). Those who developed opioid dependence were more likely to receive opioid and non-opioid pain medication (p&lt; 0.05), but these were not more likely to receive IV opioid pain medication (p &gt;0.05). However, they were more likely to receive IV opioid pain medication more frequently (p&lt; 0.05). Interestingly, patients who developed opioid dependence were more likely to follow up post-operatively and to receive anti-depressant and anti-epileptic (gabapentin and pregabalin) medications (p&lt; 0.05).

Conclusions
Here we presented data on patients who developed opioid dependence following burn injury. These patients appear to receive more pain medication and receive it more frequently. We did not find a correlation of opioid dependence to depression or patient compliance. Characterizing the patient who develops opioid dependence will better help clinicians to identify patients at risk and direct their care accordingly. Further investigation is indicated to determine the impact these factors have and how these might be mitigated.
30 A Retrospective Review of Outpatient Pain Management in the Burn Injured Population
Authors: Foster Kevin N , Spadafore Philomene , Mongelluzzo Anthony , Richey Karen 
Published: March 2022

Abstract

Introduction
Burn injuries and their associated treatments are exquisitely painful and often require hospitalization to achieve adequate pain control. Hospitalized patients have their pain managed aggressively, with rigorous monitoring. However, once patients are discharged from the hospital, the assessment of ongoing pain management becomes more difficult. The purpose of this study was to examine our current practices in the outpatient setting regarding pain management.

Methods
This was a retrospective review of patients treated in the outpatient burn clinic following discharge home from the burn center over a one-year period. Patients with a significant history of premorbid pain and those discharged initially to a post-acute facility were excluded. Patients were stratified into those requiring opioids ≤ 4 weeks/ &gt; 4 weeks, autografting/no autografting, opioids required following 95% wound closure/not required and those with and without a history of significant substance abuse.

Results
There were 206 evaluable patients in this study. The mean number of days to healing was 19.5 days. The mean percent total body surface area injured was 5% yielding a mean number of days to healing per percent total body surface area burn of 4. Overall, narcotic pain medications were discontinued 8 days prior to wound closure. The majority of patients, 83% (n=170) had their narcotic pain medications discontinued before 95% wound closure was achieved; 17% (n=36) number of patients had their narcotic pain medications continued beyond wound healing. Subgroup analysis revealed the following findings. Patients who were on narcotic pain medication &gt; four weeks following the time of injury (n=37) had a mean duration of narcotic pain therapy of 57 days compared to 11 days in patients who received ≤ four weeks (n=169, p &lt; .00001). Likewise, patients who were grafted had a longer narcotic pain duration, 28 days vs 12 days in patients who were not grafted (p &lt; .00001). Finally, the presence of previous or current substance abuse appeared to have no impact on the duration of narcotic therapy 19. 8 days vs 19.3 days.

Conclusions
Most patients followed in the burn outpatient clinic demonstrated cessation of narcotic analgesic use around the same time as burn wound closure. Factors tending to extend the duration of narcotic use included longer inpatient narcotic use, and the necessity of skin grafting for burn wound management. Interestingly, previous substance abuse history did not influence length of post-hospital narcotic use.
33 Setting the Standard: Using a National Burn Registry to Benchmark Risk Adjusted Mortality
Authors: Mandell Samuel P , Higginson Sara , Hoarle Kimberly , Hsu Naiwei , Pardon Darryl A , Phillips Bart D , Phillips Matthew H , Thompson Callie M , Weber Joan M , Bessey Palmer Q 
Published: March 2022

Abstract

Introduction
Reports of single center experience and studies of larger databases have identified several predictors of burn center mortality, including age, burn size, and inhalation injury. None of these analyses has been broad enough to allow benchmarking across burn centers. The purpose of this study was to derive a reliable risk-adjusted, statistical model of mortality based on real-life experience at many of the burn centers in the United States.

Methods
We used a national burn registry to identify 128,252 initial admissions from July 2015 through June 2020 across 103 unique burn centers. We selected 23 predictor variables, from over 50 recorded in the dataset based on completeness (at least 75% complete required) and clinical significance. Missing data were multiply imputed with a Bayesian Ridge Regression estimator. All data analysis was performed in Python using Numpy and Scikit-Learn libraries. We used Gradient boosted regression (CatBoost), a form of machine learning, to predict mortality and compared this to traditional logistic regression. Model performance was evaluated with AUC and PR curves. Using the CatBoost predictions, observe to expected mortality was calculated for each center. Confidence intervals for O/E analysis in the case of mortality prediction were calculated using a custom implementation of the Clopper-Pearson method. Analyses were run on three cohorts: All patients; Patients with 10-20% TBSA; and &gt;20% TBSA.

Results
The CatBoost model achieved a test AUC of 0.982 with an average precision of 0.801. The logistic regression, by comparison, produced an AUC of 0.974 with an average precision of 0.726. While accuracy, the measure most reported in the literature, is near ceiling for both models, the CatBoost model is markedly more sensitive, leading to a substantial improvement in average precision. Because of the superiority of the CatBoost model with respect to outcome prediction, we only used CatBoost models for calculation of O/E ratio (Fig. 1).

Conclusions
Gradient boosted regression models provided greater model performance than traditional, multivariate, logistic regression. Using data from a national burn registry, we can predict burn mortality across contributing centers allowing for meaningful O/E ratios. Further, this allows for comparison of mortality across centers contributing data to the registry.
36 Common Data Elements (CDE) in Burn Care Documentation: A Single-center Retrospective Review
Authors: Dang Justin , Bernabe Rendell , Lin Joshua , Kuromaru Yuki , Pham Christopher H , Huang Samantha , Sheth Megha , Yenikomshian Haig A , Gillenwater Justin 
Published: March 2022

Abstract

Introduction
Thorough documentation is an important component of delivering quality patient care. Documentation of common data elements (CDE), defined as a precise question with a specified set of responses used across multiple databases or studies, can also assist in improving data collection. Currently, burn care does not have an existing set of CDEs despite their potential to be a reproducible and reliable system for data collection which leads to improved burn care. Our institution performed a retrospective review of patient charts to identify the consistency of our burn care documentation and highlight deficits that could be remedied by the implementation of CDEs.

Methods
This was a single-center retrospective review of patient charts from 2014-2019. Thirty-three CDEs were investigated. Two hundred four patient charts were randomly selected for review. We presented extracted CDEs as frequencies and percentages. Information was obtained from the history and physical notes, progress notes, and discharge summaries.

Results
Our review yielded 204 patient records. The note/record of some data points could not be identified and were excluded from the qualitative calculation. Of the data points that included more than 200 records, 86% percent specified the date of injury, 88% recorded the admission date, 99% reported burn etiology, 94% included total body surface area (TBSA) burned, 94% included burn thickness, 99% specified anatomic injury location, 97% included information about wound care agents/dressings, and 24% recorded the patient’s pain scores. Thirty percent (49/164) reported the presence or absence of inhalation injury. Twenty-six percent (38/148) listed reported presence or absence of non-burn related injuries. Sixty-four percent (127/200) reported presence or absence of comorbid conditions. Other data points were found with varying frequencies (Table 1).

Conclusions
Consistent documentation of burn care remains challenging and many variables are collected inconsistently. Our results highlight the need for CDEs in burn care to standardize documentation.