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Publisher: Oxford University Press   (Total: 406 journals)

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Showing 1 - 200 of 406 Journals sorted alphabetically
ACS Symposium Series     Full-text available via subscription   (SJR: 0.189, CiteScore: 0)
Acta Biochimica et Biophysica Sinica     Hybrid Journal   (Followers: 5, SJR: 0.79, CiteScore: 2)
Adaptation     Hybrid Journal   (Followers: 9, SJR: 0.143, CiteScore: 0)
Advances in Nutrition     Hybrid Journal   (Followers: 53, SJR: 2.196, CiteScore: 5)
Aesthetic Surgery J.     Hybrid Journal   (Followers: 6, SJR: 1.434, CiteScore: 1)
Aesthetic Surgery J. Open Forum     Open Access  
African Affairs     Hybrid Journal   (Followers: 66, SJR: 1.869, CiteScore: 2)
Age and Ageing     Hybrid Journal   (Followers: 90, SJR: 1.989, CiteScore: 4)
Alcohol and Alcoholism     Hybrid Journal   (Followers: 19, SJR: 1.376, CiteScore: 3)
American Entomologist     Full-text available via subscription   (Followers: 8)
American Historical Review     Hybrid Journal   (Followers: 169, SJR: 0.467, CiteScore: 1)
American J. of Agricultural Economics     Hybrid Journal   (Followers: 44, SJR: 2.113, CiteScore: 3)
American J. of Clinical Nutrition     Hybrid Journal   (Followers: 178, SJR: 3.438, CiteScore: 6)
American J. of Epidemiology     Hybrid Journal   (Followers: 197, SJR: 2.713, CiteScore: 3)
American J. of Health-System Pharmacy     Full-text available via subscription   (Followers: 52, SJR: 0.595, CiteScore: 1)
American J. of Hypertension     Hybrid Journal   (Followers: 25, SJR: 1.322, CiteScore: 3)
American J. of Jurisprudence     Hybrid Journal   (Followers: 19, SJR: 0.281, CiteScore: 1)
American J. of Legal History     Full-text available via subscription   (Followers: 9, SJR: 0.116, CiteScore: 0)
American Law and Economics Review     Hybrid Journal   (Followers: 27, SJR: 1.053, CiteScore: 1)
American Literary History     Hybrid Journal   (Followers: 16, SJR: 0.391, CiteScore: 0)
Analysis     Hybrid Journal   (Followers: 22, SJR: 1.038, CiteScore: 1)
Animal Frontiers     Hybrid Journal   (Followers: 1)
Annals of Behavioral Medicine     Hybrid Journal   (Followers: 16, SJR: 1.423, CiteScore: 3)
Annals of Botany     Hybrid Journal   (Followers: 38, SJR: 1.721, CiteScore: 4)
Annals of Oncology     Hybrid Journal   (Followers: 56, SJR: 5.599, CiteScore: 9)
Annals of the Entomological Society of America     Full-text available via subscription   (Followers: 10, SJR: 0.722, CiteScore: 1)
Annals of Work Exposures and Health     Hybrid Journal   (Followers: 34, SJR: 0.728, CiteScore: 2)
Antibody Therapeutics     Open Access  
AoB Plants     Open Access   (Followers: 4, SJR: 1.28, CiteScore: 3)
Applied Economic Perspectives and Policy     Hybrid Journal   (Followers: 17, SJR: 0.858, CiteScore: 2)
Applied Linguistics     Hybrid Journal   (Followers: 59, SJR: 2.987, CiteScore: 3)
Applied Mathematics Research eXpress     Hybrid Journal   (Followers: 1, SJR: 1.241, CiteScore: 1)
Arbitration Intl.     Full-text available via subscription   (Followers: 21)
Arbitration Law Reports and Review     Hybrid Journal   (Followers: 14)
Archives of Clinical Neuropsychology     Hybrid Journal   (Followers: 30, SJR: 0.731, CiteScore: 2)
Aristotelian Society Supplementary Volume     Hybrid Journal   (Followers: 3)
Arthropod Management Tests     Hybrid Journal   (Followers: 2)
Astronomy & Geophysics     Hybrid Journal   (Followers: 44, SJR: 0.146, CiteScore: 0)
Behavioral Ecology     Hybrid Journal   (Followers: 52, SJR: 1.871, CiteScore: 3)
Bioinformatics     Hybrid Journal   (Followers: 338, SJR: 6.14, CiteScore: 8)
Biology Methods and Protocols     Hybrid Journal  
Biology of Reproduction     Full-text available via subscription   (Followers: 9, SJR: 1.446, CiteScore: 3)
Biometrika     Hybrid Journal   (Followers: 20, SJR: 3.485, CiteScore: 2)
BioScience     Hybrid Journal   (Followers: 29, SJR: 2.754, CiteScore: 4)
Bioscience Horizons : The National Undergraduate Research J.     Open Access   (Followers: 1, SJR: 0.146, CiteScore: 0)
Biostatistics     Hybrid Journal   (Followers: 17, SJR: 1.553, CiteScore: 2)
BJA : British J. of Anaesthesia     Hybrid Journal   (Followers: 185, SJR: 2.115, CiteScore: 3)
BJA Education     Hybrid Journal   (Followers: 65)
Brain     Hybrid Journal   (Followers: 68, SJR: 5.858, CiteScore: 7)
Briefings in Bioinformatics     Hybrid Journal   (Followers: 50, SJR: 2.505, CiteScore: 5)
Briefings in Functional Genomics     Hybrid Journal   (Followers: 3, SJR: 2.15, CiteScore: 3)
British J. for the Philosophy of Science     Hybrid Journal   (Followers: 36, SJR: 2.161, CiteScore: 2)
British J. of Aesthetics     Hybrid Journal   (Followers: 25, SJR: 0.508, CiteScore: 1)
British J. of Criminology     Hybrid Journal   (Followers: 604, SJR: 1.828, CiteScore: 3)
British J. of Social Work     Hybrid Journal   (Followers: 86, SJR: 1.019, CiteScore: 2)
British Medical Bulletin     Hybrid Journal   (Followers: 6, SJR: 1.355, CiteScore: 3)
British Yearbook of Intl. Law     Hybrid Journal   (Followers: 34)
Bulletin of the London Mathematical Society     Hybrid Journal   (Followers: 4, SJR: 1.376, CiteScore: 1)
Cambridge J. of Economics     Hybrid Journal   (Followers: 70, SJR: 0.764, CiteScore: 2)
Cambridge J. of Regions, Economy and Society     Hybrid Journal   (Followers: 12, SJR: 2.438, CiteScore: 4)
Cambridge Quarterly     Hybrid Journal   (Followers: 10, SJR: 0.104, CiteScore: 0)
Capital Markets Law J.     Hybrid Journal   (Followers: 2, SJR: 0.222, CiteScore: 0)
Carcinogenesis     Hybrid Journal   (Followers: 2, SJR: 2.135, CiteScore: 5)
Cardiovascular Research     Hybrid Journal   (Followers: 14, SJR: 3.002, CiteScore: 5)
Cerebral Cortex     Hybrid Journal   (Followers: 48, SJR: 3.892, CiteScore: 6)
CESifo Economic Studies     Hybrid Journal   (Followers: 22, SJR: 0.483, CiteScore: 1)
Chemical Senses     Hybrid Journal   (Followers: 1, SJR: 1.42, CiteScore: 3)
Children and Schools     Hybrid Journal   (Followers: 6, SJR: 0.246, CiteScore: 0)
Chinese J. of Comparative Law     Hybrid Journal   (Followers: 5, SJR: 0.412, CiteScore: 0)
Chinese J. of Intl. Law     Hybrid Journal   (Followers: 22, SJR: 0.329, CiteScore: 0)
Chinese J. of Intl. Politics     Hybrid Journal   (Followers: 10, SJR: 1.392, CiteScore: 2)
Christian Bioethics: Non-Ecumenical Studies in Medical Morality     Hybrid Journal   (Followers: 10, SJR: 0.183, CiteScore: 0)
Classical Receptions J.     Hybrid Journal   (Followers: 27, SJR: 0.123, CiteScore: 0)
Clean Energy     Open Access   (Followers: 1)
Clinical Infectious Diseases     Hybrid Journal   (Followers: 69, SJR: 5.051, CiteScore: 5)
Communication Theory     Hybrid Journal   (Followers: 24, SJR: 2.424, CiteScore: 3)
Communication, Culture & Critique     Hybrid Journal   (Followers: 27, SJR: 0.222, CiteScore: 1)
Community Development J.     Hybrid Journal   (Followers: 27, SJR: 0.268, CiteScore: 1)
Computer J.     Hybrid Journal   (Followers: 9, SJR: 0.319, CiteScore: 1)
Conservation Physiology     Open Access   (Followers: 3, SJR: 1.818, CiteScore: 3)
Contemporary Women's Writing     Hybrid Journal   (Followers: 9, SJR: 0.121, CiteScore: 0)
Contributions to Political Economy     Hybrid Journal   (Followers: 6, SJR: 0.906, CiteScore: 1)
Critical Values     Full-text available via subscription  
Current Developments in Nutrition     Open Access   (Followers: 2)
Current Legal Problems     Hybrid Journal   (Followers: 29)
Current Zoology     Full-text available via subscription   (Followers: 3, SJR: 1.164, CiteScore: 2)
Database : The J. of Biological Databases and Curation     Open Access   (Followers: 9, SJR: 1.791, CiteScore: 3)
Digital Scholarship in the Humanities     Hybrid Journal   (Followers: 14, SJR: 0.259, CiteScore: 1)
Diplomatic History     Hybrid Journal   (Followers: 21, SJR: 0.45, CiteScore: 1)
DNA Research     Open Access   (Followers: 5, SJR: 2.866, CiteScore: 6)
Dynamics and Statistics of the Climate System     Open Access   (Followers: 4)
Early Music     Hybrid Journal   (Followers: 17, SJR: 0.139, CiteScore: 0)
Econometrics J.     Hybrid Journal   (Followers: 32, SJR: 2.926, CiteScore: 1)
Economic J.     Hybrid Journal   (Followers: 113, SJR: 5.161, CiteScore: 3)
Economic Policy     Hybrid Journal   (Followers: 46, SJR: 3.584, CiteScore: 3)
ELT J.     Hybrid Journal   (Followers: 24, SJR: 0.942, CiteScore: 1)
English Historical Review     Hybrid Journal   (Followers: 56, SJR: 0.612, CiteScore: 1)
English: J. of the English Association     Hybrid Journal   (Followers: 17, SJR: 0.1, CiteScore: 0)
Environmental Entomology     Full-text available via subscription   (Followers: 11, SJR: 0.818, CiteScore: 2)
Environmental Epigenetics     Open Access   (Followers: 2)
Environmental History     Hybrid Journal   (Followers: 26, SJR: 0.408, CiteScore: 1)
EP-Europace     Hybrid Journal   (Followers: 3, SJR: 2.748, CiteScore: 4)
Epidemiologic Reviews     Hybrid Journal   (Followers: 9, SJR: 4.505, CiteScore: 8)
ESHRE Monographs     Hybrid Journal  
Essays in Criticism     Hybrid Journal   (Followers: 19, SJR: 0.113, CiteScore: 0)
European Heart J.     Hybrid Journal   (Followers: 66, SJR: 9.315, CiteScore: 9)
European Heart J. - Cardiovascular Imaging     Hybrid Journal   (Followers: 10, SJR: 3.625, CiteScore: 3)
European Heart J. - Cardiovascular Pharmacotherapy     Full-text available via subscription   (Followers: 2)
European Heart J. - Quality of Care and Clinical Outcomes     Hybrid Journal  
European Heart J. : Case Reports     Open Access  
European Heart J. Supplements     Hybrid Journal   (Followers: 8, SJR: 0.223, CiteScore: 0)
European J. of Cardio-Thoracic Surgery     Hybrid Journal   (Followers: 9, SJR: 1.681, CiteScore: 2)
European J. of Intl. Law     Hybrid Journal   (Followers: 200, SJR: 0.694, CiteScore: 1)
European J. of Orthodontics     Hybrid Journal   (Followers: 5, SJR: 1.279, CiteScore: 2)
European J. of Public Health     Hybrid Journal   (Followers: 20, SJR: 1.36, CiteScore: 2)
European Review of Agricultural Economics     Hybrid Journal   (Followers: 10, SJR: 1.172, CiteScore: 2)
European Review of Economic History     Hybrid Journal   (Followers: 30, SJR: 0.702, CiteScore: 1)
European Sociological Review     Hybrid Journal   (Followers: 43, SJR: 2.728, CiteScore: 3)
Evolution, Medicine, and Public Health     Open Access   (Followers: 12)
Family Practice     Hybrid Journal   (Followers: 16, SJR: 1.018, CiteScore: 2)
Fems Microbiology Ecology     Hybrid Journal   (Followers: 16, SJR: 1.492, CiteScore: 4)
Fems Microbiology Letters     Hybrid Journal   (Followers: 28, SJR: 0.79, CiteScore: 2)
Fems Microbiology Reviews     Hybrid Journal   (Followers: 32, SJR: 7.063, CiteScore: 13)
Fems Yeast Research     Hybrid Journal   (Followers: 13, SJR: 1.308, CiteScore: 3)
Food Quality and Safety     Open Access   (Followers: 1)
Foreign Policy Analysis     Hybrid Journal   (Followers: 24, SJR: 1.425, CiteScore: 1)
Forest Science     Hybrid Journal   (Followers: 8, SJR: 0.89, CiteScore: 2)
Forestry: An Intl. J. of Forest Research     Hybrid Journal   (Followers: 16, SJR: 1.133, CiteScore: 3)
Forum for Modern Language Studies     Hybrid Journal   (Followers: 6, SJR: 0.104, CiteScore: 0)
French History     Hybrid Journal   (Followers: 33, SJR: 0.118, CiteScore: 0)
French Studies     Hybrid Journal   (Followers: 21, SJR: 0.148, CiteScore: 0)
French Studies Bulletin     Hybrid Journal   (Followers: 10, SJR: 0.152, CiteScore: 0)
Gastroenterology Report     Open Access   (Followers: 2)
Genome Biology and Evolution     Open Access   (Followers: 16, SJR: 2.578, CiteScore: 4)
Geophysical J. Intl.     Hybrid Journal   (Followers: 39, SJR: 1.506, CiteScore: 3)
German History     Hybrid Journal   (Followers: 23, SJR: 0.161, CiteScore: 0)
GigaScience     Open Access   (Followers: 5, SJR: 5.022, CiteScore: 7)
Global Summitry     Hybrid Journal   (Followers: 1)
Glycobiology     Hybrid Journal   (Followers: 13, SJR: 1.493, CiteScore: 3)
Health and Social Work     Hybrid Journal   (Followers: 57, SJR: 0.388, CiteScore: 1)
Health Education Research     Hybrid Journal   (Followers: 16, SJR: 0.854, CiteScore: 2)
Health Policy and Planning     Hybrid Journal   (Followers: 24, SJR: 1.512, CiteScore: 2)
Health Promotion Intl.     Hybrid Journal   (Followers: 22, SJR: 0.812, CiteScore: 2)
History Workshop J.     Hybrid Journal   (Followers: 33, SJR: 1.278, CiteScore: 1)
Holocaust and Genocide Studies     Hybrid Journal   (Followers: 28, SJR: 0.105, CiteScore: 0)
Human Communication Research     Hybrid Journal   (Followers: 15, SJR: 2.146, CiteScore: 3)
Human Molecular Genetics     Hybrid Journal   (Followers: 9, SJR: 3.555, CiteScore: 5)
Human Reproduction     Hybrid Journal   (Followers: 72, SJR: 2.643, CiteScore: 5)
Human Reproduction Open     Open Access   (Followers: 1)
Human Reproduction Update     Hybrid Journal   (Followers: 20, SJR: 5.317, CiteScore: 10)
Human Rights Law Review     Hybrid Journal   (Followers: 62, SJR: 0.756, CiteScore: 1)
ICES J. of Marine Science: J. du Conseil     Hybrid Journal   (Followers: 58, SJR: 1.591, CiteScore: 3)
ICSID Review : Foreign Investment Law J.     Hybrid Journal   (Followers: 10)
ILAR J.     Hybrid Journal   (Followers: 2, SJR: 1.732, CiteScore: 4)
IMA J. of Applied Mathematics     Hybrid Journal   (SJR: 0.679, CiteScore: 1)
IMA J. of Management Mathematics     Hybrid Journal   (SJR: 0.538, CiteScore: 1)
IMA J. of Mathematical Control and Information     Hybrid Journal   (Followers: 2, SJR: 0.496, CiteScore: 1)
IMA J. of Numerical Analysis - advance access     Hybrid Journal   (SJR: 1.987, CiteScore: 2)
Industrial and Corporate Change     Hybrid Journal   (Followers: 9, SJR: 1.792, CiteScore: 2)
Industrial Law J.     Hybrid Journal   (Followers: 39, SJR: 0.249, CiteScore: 1)
Inflammatory Bowel Diseases     Hybrid Journal   (Followers: 47, SJR: 2.511, CiteScore: 4)
Information and Inference     Free  
Innovation in Aging     Open Access  
Integrative and Comparative Biology     Hybrid Journal   (Followers: 9, SJR: 1.319, CiteScore: 2)
Integrative Biology     Full-text available via subscription   (Followers: 6, SJR: 1.36, CiteScore: 3)
Integrative Organismal Biology     Open Access  
Interacting with Computers     Hybrid Journal   (Followers: 11, SJR: 0.292, CiteScore: 1)
Interactive CardioVascular and Thoracic Surgery     Hybrid Journal   (Followers: 7, SJR: 0.762, CiteScore: 1)
Intl. Affairs     Hybrid Journal   (Followers: 66, SJR: 1.505, CiteScore: 3)
Intl. Data Privacy Law     Hybrid Journal   (Followers: 26)
Intl. Health     Hybrid Journal   (Followers: 6, SJR: 0.851, CiteScore: 2)
Intl. Immunology     Hybrid Journal   (Followers: 3, SJR: 2.167, CiteScore: 4)
Intl. J. for Quality in Health Care     Hybrid Journal   (Followers: 36, SJR: 1.348, CiteScore: 2)
Intl. J. of Constitutional Law     Hybrid Journal   (Followers: 64, SJR: 0.601, CiteScore: 1)
Intl. J. of Epidemiology     Hybrid Journal   (Followers: 245, SJR: 3.969, CiteScore: 5)
Intl. J. of Law and Information Technology     Hybrid Journal   (Followers: 5, SJR: 0.202, CiteScore: 1)
Intl. J. of Law, Policy and the Family     Hybrid Journal   (Followers: 28, SJR: 0.223, CiteScore: 1)
Intl. J. of Lexicography     Hybrid Journal   (Followers: 10, SJR: 0.285, CiteScore: 1)
Intl. J. of Low-Carbon Technologies     Open Access   (Followers: 1, SJR: 0.403, CiteScore: 1)
Intl. J. of Neuropsychopharmacology     Open Access   (Followers: 3, SJR: 1.808, CiteScore: 4)
Intl. J. of Public Opinion Research     Hybrid Journal   (Followers: 11, SJR: 1.545, CiteScore: 1)
Intl. J. of Refugee Law     Hybrid Journal   (Followers: 38, SJR: 0.389, CiteScore: 1)
Intl. J. of Transitional Justice     Hybrid Journal   (Followers: 11, SJR: 0.724, CiteScore: 2)
Intl. Mathematics Research Notices     Hybrid Journal   (Followers: 1, SJR: 2.168, CiteScore: 1)
Intl. Political Sociology     Hybrid Journal   (Followers: 40, SJR: 1.465, CiteScore: 3)
Intl. Relations of the Asia-Pacific     Hybrid Journal   (Followers: 23, SJR: 0.401, CiteScore: 1)
Intl. Studies Perspectives     Hybrid Journal   (Followers: 9, SJR: 0.983, CiteScore: 1)
Intl. Studies Quarterly     Hybrid Journal   (Followers: 49, SJR: 2.581, CiteScore: 2)
Intl. Studies Review     Hybrid Journal   (Followers: 25, SJR: 1.201, CiteScore: 1)
ISLE: Interdisciplinary Studies in Literature and Environment     Hybrid Journal   (Followers: 2, SJR: 0.15, CiteScore: 0)
ITNOW     Hybrid Journal   (Followers: 1, SJR: 0.103, CiteScore: 0)
J. of African Economies     Hybrid Journal   (Followers: 17, SJR: 0.533, CiteScore: 1)
J. of American History     Hybrid Journal   (Followers: 46, SJR: 0.297, CiteScore: 1)
J. of Analytical Toxicology     Hybrid Journal   (Followers: 14, SJR: 1.065, CiteScore: 2)
J. of Antimicrobial Chemotherapy     Hybrid Journal   (Followers: 15, SJR: 2.419, CiteScore: 4)
J. of Antitrust Enforcement     Hybrid Journal   (Followers: 1)
J. of Applied Poultry Research     Hybrid Journal   (Followers: 5, SJR: 0.585, CiteScore: 1)
J. of Biochemistry     Hybrid Journal   (Followers: 41, SJR: 1.226, CiteScore: 2)
J. of Breast Imaging     Full-text available via subscription  
J. of Burn Care & Research     Hybrid Journal   (Followers: 10, SJR: 0.768, CiteScore: 2)

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Similar Journals
Journal Cover
Journal of Burn Care & Research
Journal Prestige (SJR): 0.768
Citation Impact (citeScore): 2
Number of Followers: 10  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 1559-047X - ISSN (Online) 1559-0488
Published by Oxford University Press Homepage  [406 journals]
  • 484 Application of Adhesive Hydrocolloid Dressing for Management of
           Hypertrophic Burn Scars in Pediatric Patients
    • Authors: Jain A; Warthman R, Richey K, et al.
      Abstract: IntroductionManagement of hypertrophic scarring after burn injury can be challenging, especially in pediatric patients as it affects not only appearance and joint function but also growth and acquisition or progression of developmental milestones. Routinely utilized non-invasive scar management techniques applied to immature scars include pressure garments, scar massage, and inserts. These techniques may be used alone or in combination to modulate immature scars, however each have limitations related to effort, location of scar, presence of wounds, patient compliance and cost.MethodsThis is a case series of five pediatric burn patients with immature hypertrophic burn scars in areas traditionally found to be difficult to manage, including fingers, toes, webspaces and other areas with incongruent skin contour. Patients were treated with application of an Adhesive Hydrocolloid Dressing (AHD) at a regional burn center from 2017-2018.ResultsFive patients with severe hypertrophic scaring and who failed traditional management due to various limitations, were treated with application of AHD as a rescue measure. The mean (range) age was 3 (2-5) years, mean (range) TBSA was 24 (1-64)%. The AHD was applied to 17 sites with a range of 1-7 sites per patient. Most common site of application was web spaces of feet or hand (10 sites). The AHD was applied and left in place for 3-7 days. Total treatment duration ranged from 25-218 days. Application of AHD resulted in progressive improvement in pliability in all cases both subjectively and objectively using modified Vancouver scar scale. Two sites of scars that initially were banded and/or firm, improved to yielding with an observed decrease in scar height. AHD was applied adjacent to open wounds without affecting wound care. Also, increased compliance with the AHD was noted when compared with other approaches. No adverse effects were noted during treatment in this small patient cohort.ConclusionsOur case series suggest that AHD provided a valuable tool in managing immature hypertrophic burn scars in challenging locations. Good compliance was noted, with anecdotal reports of improved ease of care and reduced number of garment changes. Controlled studies are needed to fully evaluate the efficacy and safety of AHD for scar management.Applicability of Research to PracticeHydrocolloid dressings should be considered as an adjunct for immature hypertrophic scar management, particularly for location not amenable to common scar management techniques.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.377
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 81 Cell Free DNA as a Prognostic Factor in Pediatric Burns - Preliminary
           Results
    • Authors: Shoham Y; Sharon N, Krieger Y, et al.
      Abstract: IntroductionDespite great advances in the treatment of pediatric burns, useful prognostic markers are sparse. During the past years there has been increasing interest in circulating plasma cell free DNA (CFD) as a potential marker for tissue injury, however current methods for CFD analysis are impractical for routine laboratory use due to the cost and time needed to perform them. We have developed a novel rapid direct fluorescent assay for CFD quantification that allows obtaining accurate, fast and inexpensive measurements, and already published its potential use in quantifying admission CFD levels as a prognostic factor in adult burns. The aim of this study was to use this technique for measuring admission plasma CFD levels in pediatric burn patients and explore the use of CFD as a potential marker and prognostic factor in pediatric burns.MethodsThis is an ongoing single center, single arm, prospective study, approved by the Institutional Review Board. Plasma CFD levels are obtained at admission from otherwise healthy hospitalized pediatric burn patients, 0–18 years old, within 24 hours of injury. DNA levels are quantified using the fluorochrome technique which does not require prior processing of samples, i.e. DNA extraction and amplification. The method was tested in comparison with the gold standard, Quantitative PCR, and was found to be in good correlation of R2=0.9987 (p<0.0001). Variables recorded and compared include demographic data, burn cause and depth, TBSA, hospitalization days and number of surgical procedures.ResultsTo date 16 pediatric burn patients have been enrolled, 8 female and 8 male, aged 4.0±4.5 years old, the majority (11/16=69%) suffering from scald burns. The average TBSA involved was 15.3±10.8%, and the average hospitalization was 15.6±10.2 days. The average CFD level was 1747±1215 ng/ml. There is a significant correlation between CFD levels and hospitalization days (R2=0.31, AUC=0.854, p=0.027). We did not find significant correlations with TBSA and burn depth, however, we found a strong significant correlation between the multiplication of the CFD levels by TBV (Total Burn Volume, a term previously described as TBSA*burn depth, either 2 for partial thickness, 3 for full thickness, and 2.5 for mixed depth) and hospitalization days (R2=0.51, AUC=0.98, p=0.002). There was also a significant correlation between CFD levels and the number of surgical procedures (R2=0.6, p=0.02).ConclusionsAdmission CFD levels may serve as a prognostic factor in pediatric burns. Larger patient groups are needed in order to further strengthen these results.Applicability of Research to PracticeFuture routine use of CFD levels can be made possible and cost-effective by use of the rapid fluorometric assay.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.083
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 80 Early Hyperbaric Oxygen Treatment Attenuates Burn-Induced
           Neuroinflammation by Inhibiting the Galectin-3-Dependent Toll-Like
           Receptor-4 Pathway
    • Authors: Huang S.
      Abstract: IntroductionHyperbaric oxygen (HBO) treatment has been proven to decrease neuroinflammation in rats. This study aimed to determine the potential mechanism underlying the anti-inflammatory effects of HBO treatment on burn-induced neuroinflammation in rats.MethodsThirty-six adult male Sprague-Dawley (SD) rats were randomly assigned to the following six groups (n = 6 per group): (1) sham burn with sham HBO treatment; (2) sham burn with HBO treatment; (3) burn with one-week sham HBO treatment; (4) burn with two-week sham HBO treatment; (5) burn with one-week HBO treatment; and (6) burn with two-week HBO treatment. SD rats that received third-degree burn injury were used as a full-thickness burn injury model. Subsequently, we analyzed the expression of proteins involved in the galectin-3 (Gal-3)-dependent Toll-like receptor-4 (TLR-4) pathway through enzyme-linked immunosorbent assay (ELISA), immunohistochemistry (IHC) analysis, and Western blotting.ResultsA behavior test was also conducted, which revealed that HBO treatment significantly suppressed mechanical hypersensitivity in the burn with HBO treatment group compared to the burn with sham HBO treatment group (p < 0.05). ELISA results showed that tumor necrosis factor α (TNF-α) and interleukin 1 beta (IL-1β) levels in the dorsal horn of the spinal cord and the skin significantly decreased in the burn with HBO treatment group compared with the burn with sham HBO treatment group (p < 0.05). Western blotting results demonstrated that HBO treatment significantly reduced the expression of Gal-3 and TLR-4 in the dorsal horn of the spinal cord in the burn with HBO treatment group compared with the burn with sham HBO treatment group (p < 0.05). IHC analysis showed that the expression of Gal-3, TLR-4, CD68 and CD45 in the dorsal horn of the spinal cord was significantly lower in the burn with HBO treatment group than in the burn with sham HBO treatment group (p < 0.05), and the expression of CD68 and macrophage migration inhibitory factor (MIF) in the right hind paw skin was significantly lower. The expression of vimentin and fibroblast growth factor in the right hind paw skin was significantly higher after HBO treatment (p < 0.05).ConclusionsThis study proved that early HBO treatment relieves neuropathic pain, inhibits the Gal-3-dependent TLR-4 pathway, and suppresses microglia and macrophage activation in a rat model.Applicability of Research to PracticeThis finding illustrates that HBO treatment may be useful for ameliorating burn injury-induced neuropathic pain.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.082
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 483 Therapy Standards for the Critically Ill Burn Patient
    • Authors: Greiser C; Richey K, Murray D, et al.
      Abstract: IntroductionThe critically ill burn patient requires complex rehabilitative care that must be frequently modified to respond to changes in the patient’s physiological status, the use of pharmacological agents and surgical interventions. In our center we routinely discontinue splints when patients are on vasopressors, however there is a lack of evidence to guide the therapist regarding best practice in this situation. The purpose of this survey was to explore current therapy practices in burn centers for this patient population.MethodsAn anonymous, internet-based 8-item survey was distributed to burn therapists at North American burn centers and units. Descriptive statistics were performed.ResultsThere were 52 respondents with complete surveys. Respondents were asked if they had written guidelines/protocols to determine appropriate therapy treatment for ICU patients, 48% (n=25) responded yes and 52% (n=27) responded no. However, 85% responded that they had unwritten guidelines/protocols for determining appropriate treatments. The determination whether a critically ill patient could participate in therapy was most often a joint decision between the Therapist / Physician / Nurse (58%). Far less frequently, this determination was made by the therapist independently (15%) or the Therapist and Physician in combination (13%). Participants were asked if they had specific guidelines/protocols to modify and/or terminate therapy in the ICU, with 73% responding yes. Of those that responded yes, the most commonly cited therapies were range of motion and splinting 55% each. This was followed by frequency / duration of therapy (49%) and elevation (43%). When asked about patients on vasopressors, 87% did not routinely discontinue splints and 96% did not routinely discontinue range of motion. Other indications noted for discontinuing splints included edema and skin integrity. Range of motion was discontinued immediately post-autografting and for physiological instability.ConclusionsOur results demonstrated that most respondents do not routinely discontinue splints in the face of vasopressor therapy. The survey identified other areas of both agreement and divergence, however it is important to note that this reflects current practice and expert opinion rather than high level evidence. Over half of all respondents do not have formal protocols to standardize and guide the care of their patients. Clinical trials designed to evaluate the impact of practice variations on patient outcomes are needed.Applicability of Research to PracticeThis study emphasizes the need to develop strong evidence-based rehabilitative practice guidelines for the critically ill burn patient.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.376
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • American Burn Association 51st Annual Meeting
    • PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 124 Coping with Pediatric Burn Injury - Challenges from the Survivor Point
           of View
    • Authors: Rimmer R; Bay C, Kalil E, et al.
      Abstract: IntroductionThe known challenges faced by hospitalized pediatric burn patients include painful surgical procedures, dressing changes, physical/occupational therapies, and time away from family & friends. Few empirical studies have investigated the issues pediatric survivors judge as most difficult in the post-hospital phase of survival. This study sought to provide survivors with an opportunity to define these issues.MethodsIn stage one, burn-injured youth were asked to respond to the open-ended statement “The hardest thing about being burned is..” Seven themes were derived from the responses: People Staring at Me, Being Bullied, Remembering When I was Burned, Having Additional Surgeries, My Scars, Getting Questions About My Burns,& the Pain & Itching, During the second phase participants were asked to rate each item on a 4-point scale ranging from (1) Not at all to (4) Really a lot.ResultsParticipants included burn survivors (n=164) mean age 13.7 years, male (n=74) female (n=88), average age at burn of 6.1 yrs. with (77%) reporting a combination of visible/hidden scars, & minority (55%), white (34%). Things that bothered more than 50% on some level: Remembering When I was Burned (62%), People Staring (61%), Getting Unwanted Questions (59%) & My Scars (54%). Girls were bothered significantly more often by Remembering the Burn (p=.04) My Scars (p=.01) and Pain/Itch (p=.04). Those with both visible and hidden scars were more bothered by Staring (p≤.001) and Having Additional Surgeries (p=.005). Youth with TBSA ≥ 50% were more bothered by Staring (p=.01), Having Additional Surgeries (p=.001) and Questions About My Burns (p=.006) than smaller burns. African American and Hispanics were more sensitive to staring than Whites (p=.05).ConclusionsThis study provides insight into the difficulties faced by pediatric burn survivors and reveals the psycho/social challenges they endure. Support groups, burn centers and camps as well as psychotherapists should be addressing these issues and providing constructive interventions to help burn-injured youth address and respond to them. Special consideration should be given to minority and female patients as well as those with large burns and visible scarring.Applicability of Research to PracticeFindings can be used to educate burn care professionals and rehabilitative programs about the specific needs burn-injured youth have outlined as problematic for them. Comprehensive information and supportive strategies should be developed to augment surgical/medical treatment. Arming patients with constructive ways of coping can help to improve their psychosocial outcome and functioning.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.125
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 79 Burn Injury Alters Pulmonary Neutrophil Extracellular Trap (NET)
           Formation
    • Authors: Sakuma M; Khan M, Yasuhara S, et al.
      Abstract: IntroductionIt is well known that burn patients suffer from serious lung complications such as acute respiratory distress syndrome, acute lung injury and pneumonia. However, the reasons for the development of these conditions after burn injury (BI) are not clearly understood. Several studies have been examined the importance of macrophages after burn injury. However, the involvement of neutrophils in lung complications after BI has not been studied in detail. Particularly, the importance of recently identified neutrophil extracellular traps (NETs) in the lungs after BI is unknown. NETs are considered to help trap infectious agents to protect the host; however, excess NETs could damage and destroy the airways and cause lung dysfunction. We established an in vivo model to study NETosis in the lungs after BI using an LPS model and investigated neutrophil behavior in burn injured individuals with/without LPS-mediated pneumonia.MethodsWe have first created a 15% body burn, and instilled various amounts of LPS (0–50 µg/kg) into the airways of BALB/c mice. After various time points (30mins, 3 h, 16 h, 1-7day), we have collected bronchoalveolar lavage (BAL) fluid, and lung tissues. Immune cells present in the BAL fluid were deposited on slides by Cytospin preparations, stained and quantified by microscopy. DNA-protein complexes present in the BAL supernatant and lung tissues were analyzed by agarose gel electrophoresis and PicoGreen assays. Presence of a NET marker, citrullinated histone, and further quantification of neutrophils with MPO in the lung, were analyzed by Western blots and immunohistochemistry.ResultsThe data obtained from these studies show that neutrophils are not detectable in the airways under baseline or after BI; however, different numbers of neutrophils and amounts of NETs were present under various experimental conditions and time points-post BI. These data show that we could measure NET components in the airways of mice instilled with LPS after BI.ConclusionsWe have successfully established a mouse model to study pulmonary NETosis in BI, and optimized the range of LPS concentrations and time points necessary to observe differences in NETosis under various experimental conditions. BI reduces the LPS-mediated pulmonary innate immune response. A decrease in innate immune response may be responsible for the increase in pneumonia incidence in patients with BI.Applicability of Research to PracticeThis model should help understand the roles of NETs in pulmonary dysfunction after BI, and for testing potential drugs for correcting NET-mediated lung complications.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.081
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 528 Does Split Thickness Graft Grow from bottom up in Large Burn
           Injury'
    • Authors: Ghahary A; Papp A, Pourghadiri A, et al.
      Abstract: IntroductionIt is well established that autologous split thickness skin graft is necessary for the survival of patients with large burns and skin defects. As in patients, our preliminary study in pig showed that a thin partial thickness graft became remarkable thicker within 20 days. Here, we have asked the question of whether a partial thickness skin graft grows from bottom up in a large skin injury such as burn. To answer this question, we hypothesized that growth of split thickness graft should be from bottom up through conversion of immune cells into collagen producing skin cells.MethodsIn this study, we have used a preclinical Yorkshire pig as a model whose skin thickness and adherence to the underlying structures are similar to those of human skin. The partial thickness graft at 0.015 inch/ 0.38 mm was harvested by an electrical dermatome and meshed at 3:1 ratio and grafted on 50 x 50 x 3 mm full thickness wound in pigs. New tissue formation was evaluated in 8 mm in diameter punches taken on day 10 and 20 post-operation. Tissue samples were processed, sectioned and co-stained for immune cell markers (CD45) and type I collagen.ResultsThe finding revealed that a partial thickness graft grew from bottom up and reached to almost the same level as uninjured skin within 60 days post operation. Further analysis revealed that more than 7,000 cubic mm new tissue was formed from the bottom up of large full thickness wounds in pig receiving partial thickness (0.38 mm) meshed grafts. The result of immuno- staining identified a large number of cells, which co-expressed immune cell marker (CD45) and collagen on day 10 post operation. Interestingly, as the number of these cells reduced on day 20, most of these cells became positive for collagen production.ConclusionsThe early thickening of partial thickness graft is likely happening through a major contribution of infiltrated immune cells that convert into mainly collagen producing fibroblasts in large burn injuries.Applicability of Research to PracticeIdentifying the factors responsible for conversion of immune cells to skin cells would make it possible to topically apply these factors to promote the healing and reduce inflammation in large burn injury.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.417
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 481 Orthognathic Surgery in Pediatric Burn Patients
    • Authors: Starr B; Morrison J, Billmire D.
      Abstract: IntroductionThe devastating impact of burn contractures on the developing pediatric skeleton has been well documented. However, there is a paucity of literature specifically related to pediatric head and neck burns and the surgical treatment of secondary craniofacial growth restriction.MethodsAn IRB-approved retrospective review was performed, examining records of head and neck burn patients treated with orthognathic surgery at a single institution from 1997 to 2017. Demographics, type of injury, TBSA, type and number of operations, age at operation, indications and cephalometric data were recorded.ResultsEight patients met inclusion criteria with an average age of 4.6 years at initial burn. The average TBSA and head and neck involvement was 22.6% and 7.3%, respectively. The mean age at orthognathic surgery was 16.3 years. The most common indications for orthognathic surgery were severe class II malocclusion and retrognathia. Four patients underwent combination bilateral split sagittal osteotomy (BSSO) with mandibular advancement and genioplasty; two patients underwent isolated BSSO advancement; one underwent combination Le Fort I osteotomy maxillary advancement, mandibular BSSO and genioplasty; and one underwent isolated genioplasty. The mean mandibular advancement was 10.6 mm. Each patient underwent an average of 5.1 secondary operations for constricting burn scars of the lower-mid face and neck (figure 1).ConclusionsPotential sequelae of burns to the head and neck in the pediatric population include retrognathia, micrognathia, class II malocclusion, and even obstructive sleep apnea.Applicability of Research to PracticeThe multidisciplinary team must be aware of the long-term implications of these injuries and plan accordingly for orthognathic surgery and multiple secondary reconstructive operations.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.375
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 340 Autologous Regenerative Epidermal Suspension (RES™): A Case
           Study
    • Authors: Chang K; Levin J, Sangji N, et al.
      Abstract: IntroductionBurn care is trending toward a minimally invasive approach, encompassing enzymatic debridement, the MEEK meshing system, and now, with FDA approval of the RES™, the use of a point-of-care spray autologous skin cell suspension (ASCS). Recent, randomized controlled trials utilizing ASCS indicate a 97.5% and 32% reduction in donor skin requirements compared to conventional grafting techniques for deep partial and full thickness burns, respectively. We present our initial experience with RES™ for the treatment of a severe burn injury treated under Investigational Device Exemption (IDE 15945 NCT029992249).MethodsOur center enrolled a 52-year-old man with a 60% TBSA third degree flame burn into a prospective uncontrolled observational study evaluating the use of ASCS for the treatment of patients with life-threatening burn injuries and limited donor skin. Patient and injury demographics, treatments, outcomes, photographs, and complications were documented per Sponsor protocol.ResultsAfter initial excision and allografting of all burn sites, the patient required two separate procedures to obtain definitive closure. The first procedure occurred on PBD 19 where ASCS was applied to the right and left arms, left hand, and right leg in combination with 4:1, 1:1, and 6:1 meshed autografts, respectively (Fig. 1); 30% TBSA was treated, in addition to the required donor sites (Fig 2.). The second procedure occurred on PBD 40 for closure of remaining open areas using 6:1 with ASCS (20%TBSA). Notable results included a shortened length of stay (68 days compared to a historical 90 days), minimal hypertrophic scarring, partial closure of 4:1 interstices by POD #4 and a completely healed donor site on POD #4. The patient required one surgical release and grafting for reconstruction.ConclusionsMinimally invasive burn care is the current trend and a point-of care technology that allows for reduction in donor site size for autologous coverage is one such component. RES™ is now FDA approved for the treatment of acute thermal burn injuries in patients 18 years of age and older. This patient had an excellent outcome with a decreased length of stay and minimal reconstructive needs.Applicability of Research to PracticeWith increasing use of enzymatic debridement and the resulting dermal preservation, the role of sprayed ASCS (which includes keratinocytes, fibroblasts, and melanocytes) may increase dramatically.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.251
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 123 Social Media and Burns: A Staged Informational Program for Burn Care
           Specialists to Support Safe and Effective use for Burn Patients
    • Authors: Giordano M; Gelashvili M.
      Abstract: IntroductionSocial Media has become a widely used platform for communication and knowledge acquisition. However, along with the beneficial aspects to those who are burned, are concerns that exist as well.MethodsA phenomenological study was conducted describing the meaning of social media for young adult burn survivors. Five essential themes were illuminated as: identity, connectivity, social support, privacy, and making meaning.ResultsAn evidenced based program has been designed to enlighten and educate the burn team to effectively disseminate the pros and cons of using social media to facilitate the healing process, while addressing safety and privacy concerns. Using a staged approach, identified concepts are introduced at appropriate times during hospitalization. Based on assessed need during the acute, convalescent and discharge phases of hospitalization, interventions related to use of social media are addressed, complementing traditional care. An accompanying booklet entitled, “Using Social Media to Help Connect, Gain Support, and Inspire: An informational guide for burn survivors” was developed to accompany this program. It was designed to distribute during the discharge phase. It was validated by burn care experts and social media experts, earning an overall CVI of 3.9 /4. The readability level was established at 5.324.ConclusionsCurrent trends in use of technology in health care and promotion indicate the importance of including safe and effective use of social media as part of the plan of care for burn patients. This program addresses ways to accomplish this.Applicability of Research to PracticeNurses and the burn team can participate in helping burn survivors tell their stories, and consider ways that assist them to self-identify and connect to others, using social media as a vehicle. Social media can supplement face to face connections and provide additional means for burn survivors to connect as they transition to a new normal.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.124
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 292 Use of Fibrin Sealant for Split Thickness Skin Graft Fixation
           Decreases Post-Operative Pain when Compared to Staple Fixation
    • Authors: Burton T; Al Kassis S, Savetamal A.
      Abstract: IntroductionBurn patients experience significant pain as a result of their injuries, and this can be exacerbated by the use of staples to affix grafts to their wounds. Staple placement can cause pulling or tearing pain upon movement, and is also associated with anxiety at the time of staple removal. The introduction of fibrin glue to secure grafts has allowed graft fixation to be completely staple-free. We sought to evaluate and compare post-operative pain in patients undergoing split thickness skin grafts (STSG) secured with fibrin glue versus those secured with staples.MethodsIRB approval was obtained for a one-year prospective study of admitted patients requiring extremity autografting at our burn center. Patients were randomized to receive autografting with either staple fixation or with fibrin glue. Seventeen patients were enrolled. The autograft dressings were left in place for at least two days, and patients were blinded to the fixation method used. Demographic data (age, % TBSA, length of stay, gender) were collected, and the Universal Pain Assessment Scale was used to document pain levels. Pain scores were obtained and averaged for each post-operative day for 4 days. Exclusion criteria for this study were: age <18, critical illness, mobility restriction, loss to follow-up, and multiple grafting procedures.ResultsThe two groups did not differ demographically. The average age was 39 in the fibrin glue group and 54 in the staple group (p=0.272). Average TBSA was 9.3% in fibrin glue group and 6.3% in staple group (p=0.479). Gender distribution was similar (43% male). Average hospital stay was nearly identical (4.6 days in the fibrin glue group and 4.4 days in the staple group, p=0.873). Patients whose grafts were affixed with fibrin glue, however, reported much less post-operative pain. The mean pain scores on each post-operative day were statistically significant: 6.43 for staples and 4.86 for fibrin glue on POD1 (p=0.033); 5.57 for staples and 3.29 for fibrin glue on POD2 (p=0.007); and 4.00 for staples and 2.29 for fibrin glue on POD3 (p=0.011). No graft loss was noted in either group.ConclusionsUse of fibrin glue decreases post-operative pain in patients undergoing extremity autografting. This study is limited by small sample size but statistical significance was evident at post-operative days 1-3 and clinically significant on post-operative day 4. This supports our hypothesis that use of fibrin glue decreases post-operative pain levels when compared to staple fixation.Applicability of Research to PracticeFibrin glue can be used instead of staples for graft fixation without graft loss. Quality improvement is shown in significantly improved post-operative patient pain scores when fibrin glue is used rather than staples.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.209
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 78 Intravenous Resuscitation Attenuates Gut Microbiome and Intestinal
           Changes after 40% TBSA Burn Injury in Swine
    • Authors: McIntyre M; Winkler C, Gomez B, et al.
      Abstract: IntroductionExtensive burns have both local and systemic effects leading to increased intestinal permeability and inflammation, which both affected by fluid shifts and intravenous (IV) resuscitation. Recent reports underscore the importance of the gut microbiome in health and disease and yet the role of the microbiome in burn outcomes remains unclear. We describe the changes in the gut microbiome in an established 40% TBSA porcine burn model, and determine the effect of IV fluid volumes on the microbiome and intestinal integrity.MethodsAnesthetized Yorkshire swine sustained 40% TBSA full-thickness burns and were randomized to different volumes of IV Lactated Ringers’: none (n=5), 15mL/TBSA/kg/day (Low; n=6), or 2mL/TBSA/kg/day (High; n=6). At baseline and days 1 and 2, fecal swabs were collected for 16s rDNA sequencing. Ileum was collected immediately after euthanasia (day 2) for western blot, histopathology, and cytokine analyses.ResultsFollowing burn injury there is a significant shift in the gut microbiome community in terms of β-diversity across time, regardless of treatment. This was also accompanied by a slight reduction in α-diversity and evenness that did not recover by day 2 regardless of treatment group. We also found a significant increase in the opportunistic pathogen Proteobacteria following injury that was attenuated by IV fluids in a dose-dependent manner, and was restored to normal levels by day 2 high group alone. Interestingly, we found a greater goblet cell area (p=0.0137) and Hsp70 levels (p=0.0465) in the high fluid group, as well as higher concentrations of SGLT1 and (P=0.0212) and caspase (P=0.0138) in the no-fluid group. Greater volumes of IV fluids generally correlated with decreased ileum concentrations of pro-inflammatory cytokines (e.g., IL-1α, IL-6, IL-12).ConclusionsAggressive fluid resuscitation is critical for improving outcomes following a large burn injury. Despite specific differences in certain species, we show a marked shift in the gut microbiome community regardless of IV fluid. However, we found that high levels of fluids are anti-apoptotic, anti-inflammatory, and alter critical protein expression in the ileum.Applicability of Research to PracticeSevere burn injury elicits a shift in the gut microbiome and protein expression that may be implicated in the onset of infections complications such as sepsis. This research highlights the need to explore the microbiome for diagnostic and therapeutic purposes to improve burn outcomes.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.080
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 241 Effect of Methamphetamine Abuse on Discharge Opioid Requirements in
           Burn Injured Patients
    • Authors: Tejiram S; Solomon E, Sen S, et al.
      Abstract: IntroductionMethamphetamine (MA) is one of the most abused stimulants in the United States. In the burn injured population, it has been linked to more frequent inhalation injuries, larger resuscitation volumes, and higher complication rates. MA use is also associated with anxiety and pain experienced during treatment and recovery. There is a paucity of literature examining the impact of MA abuse on pain control and opioid requirements in the burn injured population. The aim of this work was to examine the impact of MA abuse on discharge pain scores and opioid requirements.MethodsA retrospective review was performed on burn injured patients admitted to a burn center from 2016 to 2017. Patients whose injury were non-acute burn related, had a hospital stay <24 hours, or died were excluded. Data on demographics, burn size (TBSA), social history (SH), admission toxicity screening, discharge pain scores, length of stay (LOS), and opioid equivalents (OE) in their last 24 hours of admission were collected. OEs were determined by converting all narcotics to oral morphine equivalents.ResultsDuring the study period, 285 patients met inclusion criteria. Only 199 (69.8%) patients received a toxicity screen on admission. Among those screened, 81 (40.7%) patients were positive for MA use. In patients who received a toxicity screen, there were no differences in LOS (11.9 v 16.5 days, p=0.059), OEs (77.8 vs. 90.5, p=0.22), or OE/TBSA (16.6 vs. 18.2, p=0.65) in patients who screened positive for MA vs those screened negative. MA positive patients had higher discharge pain scores (4.37 v 3.48, p=0.03) than patients who screened negative. Given that over 30% of patients did not have a toxicity screen, we examined patients with a SH of illicit drug use. SH data was available for 275 patients (96.8%) with 150 negative SH (54.5%), and 121 positive SH (44%). There was no difference between those who had negative SHs and those with positive SHs with regards to LOS (16.1 vs. 15.8, p=0.98), or OE/TBSA (18.5 vs. 19.6, p=0.79). Patients with a positive SH used more OEs in the last 24 hours of hospitalization (92.2 vs. 72.9) but this did not reach significance (p=0.057). Patients with a positive SH of illicit drug use had higher pain scores at discharge (4.10 vs. 3.21, p=0.01).ConclusionsWe strive to obtain drug screens on all patients admitted with a burn injury, but fall short of this goal in practice. Patients who screened positive for MA use and those with a social history of illicit drug use had higher pain scores at discharge. Additional work will be necessary to fully elucidate these results and determine techniques to improve pain control.Applicability of Research to PracticeWe need to make improvements in our screening of patients for illicit substances and in controlling the pain at discharge in patients with a history of illicit drug use.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.167
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 527 Promoter CpG Methylation Status in POMC and its Role in Dyspigmented
           Burn Hypertrophic Scar
    • Authors: Carney B; Moffatt L, Simbulan-Rosenthal C, et al.
      Abstract: IntroductionBurn injuries often result in hypertrophic scar (HTS), and in many patient populations, these scars are dyspigmented. The mechanism behind dyspigmentation has not been explored, and, as such, prevention and treatment strategies for this morbidity are lacking. The mechanism by which normal cells make pigment is controlled at the apex of the pathway by pro-opiomelanocortin (POMC), which is a molecule that is synthesized and processed to its product alpha-melanocyte stimulating hormone (a-MSH). a-MSH is secreted by keratinocytes, and binds to melanocyte melanocortin receptors (MC1R) to initiate melanogenesis. In previous work, we showed that POMC protein expression is upregulated in hyper-pigmented scar compared to hypo-pigmented scar by an unknown mechanism. The methylation status of the POMC promoter was investigated as a possible root cause of dyspigmentation.MethodsDyspigmented HTSs were formed on Duroc pigs by excisional wounding. A Skin Color Catch (SCC) probe was used to determine melanin content of differentially pigmented areas of HTS in vivo. Biopsies were taken, and DNA and melanin were isolated from biopsies obtained from areas of hyper- or hypo-pigmented HTS and normally pigmented skin. Melanin from biopsies was quantified using spectrophotometry. DNA was bisulfite-converted, and amplified using 2 sets of primers to observe promoter methylation patterns in 2 different CpG islands. Amplicons were then sequenced and methylation patterns were evaluated.ResultsBy SCC, the hyper- or hypo-pigmented areas had significantly more or less melanin than normal skin (890±24 or 617±49 vs. 802±51, n=8 scars, p<0.001). This in vivo melanin determination was corroborated by the melanin extraction in the biopsies (381±50 or 84±33 vs. 147±19, n=3, p<0.001). Bisulphite-converted DNA and PCR amplification was confirmed by agarose gel electrophoresis where crisp bands were detected at 425 and 368 bp for POMC promoter islands 1 and 2. The data revealed differences in methylation of CpG islands in the POMC promoter present in the hypo- and hyper-pigmented scars compared to the normally pigmented skin.ConclusionsEpigenetic mechanisms, such as methylation, contribute to the development of dyspigmented HTS. POMC promoter methylation may be able to be altered to restore or lessen pigmentation.Applicability of Research to PracticeDue to the paucity of existing treatments for both hyper- and hypo-pigmentation in the context of burn HTS, this research will continue to strive to find a treatment for these sequelae of burn injury that delay quality of life improvements for burn survivors.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.416
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 480 Elastography-Based Quantification of Burn Scar Stiffness
    • Authors: Zuccaro J; Perez M, Mohanta A, et al.
      Abstract: IntroductionThe purpose of this study is to test the feasibility of using acoustic radiation force impulse (ARFI) ultrasound elastography to quantify the stiffness of hypertrophic burn scars. ARFI imaging is a non-invasive ultrasound technique that has been used to determine tissue stiffness in many fibroproliferative disorders including cutaneous scleroderma. Given that the technology is both objective and operator-independent, it has the potential to overcome the limitations inherent in using subjective clinical tools for assessing scar stiffness.MethodsThirteen patients from the outpatient Burn Clinic at our tertiary pediatric hospital participated in this study. Only patients with a hypertrophic burn scar that was clinically diagnosed by a burn care specialist were eligible to participate. For each participant, a section of scar as well as a section of contralateral matched normal skin were marked for ultrasound measurement. ARFI ultrasound elastography was then carried out by a trained ultrasound technician to obtain values for the elastic modulus (E) of scar and control sites. Scar thickness was also measured using conventional gray-scale ultrasound. The Wilcoxon signed-rank test was used to compare scar and control sites and the Spearman’s correlation test was used to examine the relationship between scar stiffness and thickness.ResultsThe results of this study show that hypertrophic scars are significantly stiffer than normal skin. More specifically, scarred areas were found to be approximately four times stiffer than the control sites (scar Emean = 42.68 kPa compared to control Emean = 10.05 kPa). Lastly, there was no correlation between scar stiffness and thickness (rs = 0.026; p > 0.05).ConclusionsWe have shown that ARFI ultrasound elastography can be used to discriminate between scar and normal skin and should be considered a potentially valuable tool in the armamentarium of objective scar measures. Future research should focus on establishing reference data and determining the technology’s ability to detect scar changes over time and their responsiveness to treatment in longitudinal studies.Applicability of Research to PracticeThe ability to objectively measure scar stiffness will allow clinicians to monitor scar progression (or regression) over time and evaluate response to treatment.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.374
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 392 Increased Mitochondrial Respiration and ROS Production From
           Adipose-Derived Stem Cells is Passage Dependent
    • Authors: Chao T; Chu G, Gomez B, et al.
      Abstract: IntroductionVictims of severe burn injury (over 30% of the total body surface area) experience profound hypermetabolism which prolongs wound healing. Adipose-derived stem cells (ASCs) have been proposed as an attractive solution for treating burn wounds. Moreover, the subcutaneous adipose tissue of severely burned patients normally discarded during surgical debridement is a viable source of ASCs. While previous studies found that severe burn injury alters the metabolic profile of subcutaneous adipocyte, the effect of severe burns on ASCs is largely unknown. The purpose of this study is to compare the metabolic activity of ASCs from burned patients to those from abdominoplasty patients by analyzing mitochondrial respiration and characteristics.MethodsIsolated ASCs from severely burned patients (BP, n=6) and abdominoplasty patients (AP, n=6) were grown to 80% confluency, trypsinized, and harvested for analysis at passage 2, 4, and 6. Flow cytometry was used to determine ASC cell surface markers CD90, CD105, and CD73. Mitochondrial abundance and ROS production were determined with MitoTracker Green and MitoSOX Red, respectively. JC-10 Mitochondrial Membrane Potential Assays were used to determine mitochondrial membrane integrity. Mitochondrial respiration and glycolysis were analyzed in technical quadruplicates by a Seahorse XFe24 Analyzer.ResultsNo significant differences were found in ASC surface markers, mitochondrial abundance or membrane potential among passages or between groups. A two-way ANOVA showed that there was a significant effect (p<0.01) of passages on mitochondrial ROS production. Mitochondrial respiratory states Routine, Leak (uncoupled), and Non-mitochondrial respiration was significantly higher (p<0.05) at passage 6 than passage 2 for BP, but not AP. Glycolysis significantly decreased (p<0.05) from passage 4 to 2 in AP ASCs.ConclusionsStem cell positive staining and mitochondrial activity were not different between cells from burned or non-burned humans. BP ASCs showed increased mitochondrial respiration with increasing passages. All ASCs showed increased ROS production through multiple passages.Applicability of Research to PracticeAdipose-derived stem cells from burned injured patients remain an exciting potential source for therapeutic purposes. However, increased ROS production and mitochondrial leak may cause oxidative stress that could limit the expansion of these cells ex vivo.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.293
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 439 Lessons from a Decade of Burn Disaster Planning
    • Authors: Joho B; Lozano D, Amani H.
      Abstract: IntroductionIn 2008 our burn center designed a plan to help mitigate the impact of a surge in burn patients. What was constructed is a modular toolkit addressing deficits noticed in equipment availability and knowledge of burn injury treatment. Since these modules were implemented all have been changed in ways we did not initially anticipate.MethodsOur disaster management toolkit consists of four modules: provide equipment, provide guidance, provide education, and drill. The first module consists of mobile carts equipped to treat 1-3 burn patients. The second includes guidelines suggesting treatment pathways that may be useful to an organization experiencing a burn patient surge. The third is a course developed to teach burn care to non-burn center providers. The fourth is to set up drills and practice what we have planned.ResultsWithin the first module we have struggled to keep all burn carts operational. Burn carts have been misplaced, hospitals hosting a cart have closed, equipment on the carts has been allowed to expire or been utilized without being restocked, and some of the carts have been reallocated to other uses by the host institution. Within the second module while we have not had any challenges with our written guideline we have experienced changes to our Teleburn program. Problems associated with software vendors, changing hospital ownerships, and staff turnover requires us to provide constant monitoring and maintenance of the service. Within the third module we have noticed that there is a lack of interest in full day classes on burn disaster management. Most institutions prefer shorter courses that can be integrated into their standardized education. We have addressed this by adding disaster management segments to a one hour course on general burn treatment. And lastly, drills. Our challenge is to ensure any drills that include burn patients include our burn center. Outreach to hospitals and agencies prior to drills occurring is essential to ensure we are invited to participate.ConclusionsThe modular nature of our plan allowed us to make changes to the program based on experienced setbacks. Remaining flexible and diligent in program management will minimize financial losses. Should other burn centers choose to implement a similar modular program it is vital to maintain close contact with assets that have been distributed and the staff of the referral centers and transport agencies they work with or degradation of their disaster preparedness assets will occur.Applicability of Research to PracticeWhen choosing to implement modules in the burn disaster toolkit it is important to anticipate changes that may occur so degradation of the program can be avoided.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.335
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 122 The Efficacy of Community Reintegration Programming in the Physical
           and Psychosocial Recovery of Pediatric Burn Survivors
    • Authors: Turgeon L; Bradbury C, Weed V, et al.
      Abstract: IntroductionCommunity Reintegration (CR) programming in burn rehabilitation is a crucial tool in development of resiliency and coping skills outside the hospital setting. Survivors face novel trials upon discharge, and goal-based CR programming allows patients to practice skills in a supportive environment. Few prospective studies exist to document this impact.MethodsThree surveys were utilized, with each subject completing a pre & post-outing State Trait Anxiety Inventory/State Trait Anxiety Inventory for Children (STAI) to capture short-term effects, a Pediatric Quality of Life Inventory Short Form 15 Generic Core Scale (PedsQL) before the 1st and after the 3rd outing to address mid-range impact, and an adapted Burn Outcomes Questionnaire/Young Adult Burn Outcome Questionnaire (BOQ) at baseline and after 6–12 months to identify long-term results. Caregivers completed a parent version of PedsQL at the same intervals.ResultsOf the 23 enrolled subjects, 2 were removed from the study due to incomplete data, leaving 8 subjects ages 6–8 years, 10 ages 8–12 years, and 3 ages 13–18 years. Twenty-one subjects completed the 1st STAI survey, 15 submitted the 2nd, and 9 completed the 3rd. All subjects and parents completed the 1st PedsQL, 9 parents and 8 subjects completed the 2nd. Only 3 BOQs have been returned to date. Results from the STAI surveys are detailed below in table 1.1. Overall score comparisons from the PedsQL showed increased quality of life (QOL) in 62.5% and decreased QOL in 37.5%. Data collected to date from the adapted BOQ continues to be analyzed pending receipt of surveys from the remaining participants.ConclusionsThough small, the study provides meaningful evidence that CR programming, designed and implemented by skilled professionals, improves the pediatric patient’s anxiety levels and self-reported QOL. While the first interaction exhibited the most significant change in anxiety, positive results persisted after the third encounter.Applicability of Research to PracticeBurn care professionals are constantly searching for ways to support patients as they heal. With continued focus on the psychosocial aspects of recovery, we must remain innovative in how we aid the patient through community re-entry. Goal-oriented CR programs such as this are essential to promote full recovery.Table 1.1 - Pre/Post Outing Anxiety Comparison from STAI SurveysSTAI Outing 1Average ChangeSTAI Outing 2Average ChangeSTAI Outing 3Average ChangeDecreased Anxiety55% (n=11)-8.63%50% (n=7)-1.58%55.5% (n=5)-7.64%Increased Anxiety35% (n=7)+5.35%28.6% (n=4)+2.7%33.3% (n=3)+4.27%No Change10% (n=2)N/A21.4% (n=3)N/A11.1 % (n=1)N/A
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.123
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 339 The Use of an Autologous Cell Harvesting and Processing Device in Two
           Burn Patients at an Urban Pediatric Burn Center
    • Authors: Glat P; Nanassy A, Burkey B, et al.
      Abstract: IntroductionAutologous cell suspension (ACS) is utilized in individuals with large burns to enhance skin regeneration, thus decreasing risk of infection, expediting the time to wound closure, and improving outcomes. Currently, ACS can be used as a treatment of life-threatening wounds requiring closure in patients who lack adequate available skin to harvest for conventional grafting.MethodsThe first patient was a 4 year old female with 32% total body surface area full and partial-thickness burn injuries. The patient was injured when a crock-pot of hot grease spilled on her head, trunk, flank, arms, thighs, and feet. The second patient was an 18 month old female with 21% total body surface area full and partial-thickness burn injuries to the bilateral lower extremities from being submerged her in hot bathwater by a caretaker. Both pediatric patients were treated with ACS.ResultsThe first patient’s treatment sites had reached 95-100% epithelization and all donor sites had reached 100% epithelization 14 post-ACS treatment. The first patient was discharged to a rehabilitation center 19 days post-ACS treatment. Neither patient required additional surgical interventions. The second patient’s donor sites had reached 100% epithelization and treatment areas were estimated to be healed between 70-85% 14 days post-ACS treatment. The second patient was discharged home 22 days post-ACS treatment. Neither patient experienced any unexpected treatment related adverse events.ConclusionsThe cases of these pediatric burn patients support the existing literature that suggests utilizing ACS to treat burn injuries can help decrease surgical procedures and expedite healing.Applicability of Research to PracticeACS is an alternative to cultured epithelial autografts and can be used as an adjunct to traditional skin grafts, biologic or synthetic skin substitutes that eliminates the waiting time of growing epithelial cells at an off-site laboratory. The literature suggests that ACS may help to decrease the number of surgical interventions performed, pain, and scarring by expediting healing and minimizing donor site areas in pediatric burn patients.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.250
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 291 Less is More: Utilization of Peripherally Inserted Central Catheters
           (PICC) and Midline Catheters in a Burn Unit
    • Authors: Lintner A; Kahn S.
      Abstract: IntroductionCentral venous catheters are often utilized for intravenous access in critically ill patients and can be associated with significant complications. Historically, central lines were utilized for most of the hospitalization and changed every 3 days for fear of infection. PICC’s and midline catheters however, provide a less invasive alternative to central line catheters and have an increased dwell time, requiring fewer changes over wire. The aim of this study was to gauge the impact of introduction of a dedicated PICC/Midline team in reducing central line use in the burn unit. The authors hypothesize that the increased utilization of PICC’s and Midlines will decrease the use of central line catheters and secondarily Central Line Associated Catheter Blood Stream Infections (CLABSI).MethodsA single center retrospective chart review was performed on patients admitted to the burn intensive care unit comparing two groups spanning from May 2012 to January 2018. The historical group received line changes every 3-5 days, and the current practice group utilized less triple-lumen catheters and more PICC’s and midlines leaving them in for longer periods of time. Key outcomes included central line free days and incidence of CLABSI. Data was reported in medians with 25-75% interquartile ranges.ResultsA total of 246 patients were within the study duration (Historical Group, n =126; Current n=120). Age was similar between the two groups, but median burn size decreased from 22 to 13% TBSA (p =0.0006). The current group had significantly more catheter free days (14 vs 6, p <.00001). The number of CLABSI’s per 1000 days decreased from 1.62 in the historical group to 0 in the current group (p=0.2474). Median days of dwell time per individual central line increased from 4 to 6 (p <0.001). Median number of procedures (sticks and changes over wire) decreased from 2 to 1 (p=0.006). There was no significant change in hospital LOS. Mortality decreased from 23 to 4 (p=0.0002).ConclusionsIntroduction of midline catheters and increased utilization of PICC’s was associated with an increase in central line free days and fewer infections. Catheters were left in place for a longer period of time without infection, suggesting longer dwell times are safe for burn patients. Fewer central line sticks and changes over wires were performed, exposing the patient to less risk of procedural complications. These results support the hypothesis, showing an increase utilization of PICCs and Midlines resulted in less invasive central line catheter use and a reduction in the number of CLABSI’s.Applicability of Research to PracticeThe results of this study can bring awareness to providers to explore their current practice and its potential for process improvement.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.208
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 240 A Randomized Controlled Trial of Hypnosis for Pain and Itch Following
           Burn Injury
    • Authors: Wiechman S; McMullen K, Carrougher G, et al.
      Abstract: IntroductionBurn survivors report that pruritus (also categorized as neuropathic pain) is common for years after injury and can affect all aspects of quality of life. Pharmacological interventions have not consistently shown to be effective and often have side effects. Hypnosis has been successfully used to treat burn pain and nonburn-related pruritus. We hypothesized that hypnosis would provide greater postburn itch and pain relief than the control at 48 hours, 1, 3, 6, 12-months post-intervention.MethodsFollowing IRB approval, adult burn patients who had been undergoing pharmacologic therapy (gabapentin, diphendhydramine and/or cetirizine) and who scored ≥ 4 on a 0–10 Numerical Rating Scale (NRS) for itch or pain were eligible for the study. Subjects were randomly assigned to receive 4 sessions of hypnosis or treatment as usual. Both groups continued to receive pharmacologic and topical therapy. Outcome measures included NRS for pain and itch, and the 5-D Itch Scale. We conducted an intent to treat analysis of change over time for the two treatment groups on all measures.ResultsA total of 27 patients participated in the study, 62% were Caucasian and 60% were male. There were no significant differences between the groups on any outcome measure and both groups demonstrated improved pain and itch over time. There was a large effect size for Itch as measured by the NRS (intensity) and the 5D Itch Scale from baseline to 1 month. Of note, those in the hypnosis group had a larger burn size (24.1% TBSA burn vs 14.7%); however, this was not statistically significant. Our sample size was smaller than our target enrollment due to difficulties in subject recruitment. A total of 106 eligible participants were approached for the study but only 29 consented (two were lost to follow up). Top reasons for refusal included “did not believe in hypnosis” (25%), lost to follow up after screening but prior to consent (24%), and geographic distance prohibiting return to burn center (10%).ConclusionsItch and pain seem to improve over time. Barriers to making hypnosis a feasible nonpharmacological option for patients who report burn pain and itch as impacting quality of life should be addressed.Applicability of Research to PracticeOur study demonstrates a need to educate the public about the potential benefits of hypnosis as a safe and efficacious nonpharmacological medical intervention. Further, future studies should validate the efficacy of hypnosis delivered via video or CD to reduce travel burden on patients returning for the intervention.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.166
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 37 Differentiation of Merkel Cells Precedes Innervation in Engineered Skin
           Substitutes after Grafting
    • Authors: Supp D; Hahn J, Combs K, et al.
      Abstract: IntroductionSkin substitutes have been shown to provide stable closure of excised burns, but relatively little is known about their innervation after grafting. Previous studies showed that Merkel cells—specialized neuroendocrine cells required for fine touch sensation—are regenerated in engineered skin after grafting. The current study investigated the timing of appearance and innervation of Merkel cells in engineered skin after transplantation using a mouse model.MethodsEngineered skin was prepared using primary fibroblasts and keratinocytes isolated from de-identified human skin obtained with IRB approval. After a 10-day in vitro culture period, grafts were transplanted to full-thickness excisional wounds in immunodeficient mice (N=24). Two mice were euthanized at 2, 4, 6, 8, 10, and 12 weeks after grafting, and remaining mice were euthanized at 14 weeks. Immunohistochemistry (IHC) was performed to localize the following proteins: Merkel cell markers keratin 20 (KRT20) and keratin 18 (KRT18); neuronal markers PGP9.5, expressed in all nerves and neuroendocrine cells, and neurofilament heavy polypeptide (NFH), which is highly expressed in myelinated mature nerves; neuroendocrine marker synaptophysin (SYN); and epithelial marker N-cadherin (CDH1). Engraftment was confirmed by IHC with anti-human leukocyte antigen (HLA) antibody. Native human skin biopsies were used as positive controls.ResultsKRT20+ Merkel cells were not observed in engineered skin grafts prior to transplantation. At 2 weeks after grafting, small numbers of individual KRT20/KRT18-positive Merkel cells were present in the basal epidermis of engineered skin grafts but neurons were not observed. By 4 weeks, small Merkel cell clusters were observed; these cells also expressed SYN, and were rarely associated with PGP9.5-positive neurons. Merkel cell numbers appeared to increase over time and then stabilize by 10–14 weeks in vivo. Association of NFH-positive neurons with Merkel cells was observed at 8 weeks after grafting and at later time points. Merkel cells in engineered skin were confirmed to be of human epithelial origin as shown by positive staining with human-specific anti-CDH1 antibody and anti-HLA antibody.ConclusionsThe presence of Merkel cells in engineered skin grafts in vivo precedes innervation, suggesting that neurons are not required for Merkel cell differentiation or proliferation. The absence of Merkel cells in engineered skin in vitro and their increase in number after grafting suggests that Merkel cells may arise from epithelial precursors in engineered skin that proliferate in vivo.Applicability of Research to PracticeThe results suggest that fine touch sensation may be regained by 8–14 weeks after grafting, although this must be confirmed with functional studies.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.041
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 77 Microtubule Network Disturbance is Likely the Target of
           Oxidative-Stress-Induced Mitophagy Perturbation
    • Authors: Yasuda N; Shakuo T, Kashiwagi A, et al.
      Abstract: IntroductionOxidative stress is considered one of the key mechanisms in burn injury-induced organ dysfunctions. The roles of oxidative stress in autophagy/mitophagy dysfunction have recently been discussed in basic biology, but its molecular target remained somewhat elusive. In this study, we have examined the effect of oxidative stress on the formation of microtubules (MTs), which, in normal circumstances, serves as an essential guide rail for auto/mitophagosome vesicle trafficking and thus a key component of auto/mitophagy pathway.MethodsBy stably transfecting auto/mitophagy markers in C2C12 myocyte, we have established a few new muscle cell lines, expressing mCherry-tubulin, GFP-LC3, and/or tfLC3. To monitor mitochondria and lysosomes, the cells were stained by MitoTracker DeepRed and LysoTracker Blue. The cells were cultured with or without oxidative stress by hydorgen peroxide (H2O2). The response of mitophagy was monitored by stimulating the cells with CCCP. To confirm the mitophagy turnover blockade under oxidative stress, Western Blotting was performed against mitochondria-associated LC3.ResultsNormal cells showed mitophagy-induced MT network formation. All the mitophagosomes and lysosomes traveled along the MTs. Cells under the oxidative stress, however, showed completely abolished MT network formation, and the vesicle motion was markedly inhibited. Observation of tfLC3-expressing cells demonstrated the inhibition of mitophagosome maturation. Western Blotting against mitochondria-LC3 showed the blockade of mitophagy flux under oxidative stress.ConclusionsMT network disturbance is likely the target of oxidative stress. The disturbed maturation of mitophagosome under oxidative stress is consistent with the notion that MTs are essential for vesicle fusion and thus for the turnover of mitophagy.Applicability of Research to PracticeOxidative stress-induced MT disturbance can be the pivotal key event in the critical illness-related mitochondrial dysfunction in skeletal muscles, and needs further investigation. Amelioration of the perturbed MTs may serve a novel therapeutic target in the future.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.079
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 526 Pirfenidone Inhibits Epithelial-Mesenchymal Transition (EMT) Genes in
           Keloid Keratinocytes
    • Authors: Evdokiou A; Hahn J, Supp D, et al.
      Abstract: IntroductionKeloid, a debilitating fibroproliferative disorder, is known to occur only in humans. Several years of research have identified the contribution of both fibroblasts and keratinocytes in the progression of keloid formation. There is demand for a therapeutic agent that could simultaneously impede the overactive behavior of these cell populations to prevent the development and recurrence of keloid formation. Epithelial-mesenchymal transition (EMT), which has been implicated in keloid pathology, is a process whereby epithelial cells lose their cell polarity and cell-cell adhesion, develop invasive and migratory properties, and ultimately become mesenchymal cells. Transforming growth factor-beta 1, (TGF-β1) is known to be involved in keloid development and is a regulator of EMT. Pirfenidone (PFD) is a small molecule known for its anti-fibrotic and anti-inflammatory properties both in-vitro and in-vivo in liver and lung fibrosis. For the first time, this study focuses on the ability of PFD in suppressing the EMT-like phenotype of keloid keratinocytes.MethodsKeratinocytes were cultured from normal skin and keloid scars (N=2 of each strains tested in triplicate) and were treated with or without TGF-β1 (10 ng/ml) and/or PFD (400 µg/ml). RNA was isolated and subjected to real-time RT-PCR assay to determine the changes associated with the mRNA expression levels of genes involved in EMT, namely Vimentin (VIM), Hyaluronan synthase 2 (HAS2), Frizzled 7 (FZD7), WNT5A and Cadherin 11 (CDH-11). In-vitro cell migration assay was also performed. Using one-way ANOVA analysis p<0.05 was considered statistically significant.ResultsPFD inhibited TGF-β1-induced VIM, HAS2, FZD7, and CDH-11 in both cell types but a greater reduction was noted in keloid keratinocytes approaching statistical significance. Furthermore, PFD significantly inhibited both basal- and TGF-β1-induced cell migration of both normal and keloid-derived keratinocytes and the inhibitory effect was more pronounced in keloid keratinocytes.ConclusionsPFD shows potential to inhibit EMT elicited by TGF-β1 in keloid keratinocytes, suggesting it may have therapeutic value for keloid suppression. Currently, work is in progress to confirm the changes in EMT genes at the protein levels.Applicability of Research to PracticePFD may become the first small molecule that can be introduced clinically to inhibit the pathologic actions of fibroblasts and keratinocytes simultaneously to treat abnormal scars.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.415
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 391 Cutaneous Host Metabolomic Alterations after Burn Injury in a Murine
           Model
    • Authors: Ball R; Alkhalil A, Garg G, et al.
      Abstract: IntroductionMetabolomics is the study of the biological pathways affected by the unique metabolites of an organism. This field has been extensively researched in many pathological processes such as cancer and blunt/penetrating trauma, but knowledge of the effects of thermal injury on the metabolome is comparatively limited. The aim of this study is to investigate the regulation of metabolites after an extensive thermal injury in a murine model to better understand the resulting tissue damage and identify potential therapeutic targets.MethodsDepilated mice were subjected to 30% total body surface area (TBSA) burn by submersion in 100⁰C water. Skin biopsies were taken on euthanasia at 2, 6 and 24 hours after injury (n=3 for all time points). An equal number of mice had sham procedures and biopsy collection for each time point. Samples were analyzed by ultra-performance liquid chromatography-quadrupole time-of-flight mass spectrometry (UPLC-Q-TOF-MS). Multivariate analysis, the principal components analysis (PCA), was calculated using R and to validate metabolic changes.ResultsTwo hours after burn injury, differential regulation between injured and sham animals was found in 4495 metabolites. Of these, 1733 metabolites achieved statistically significant difference (p<0.05). These metabolites have the greatest impact on the linoleic acid metabolism pathway. At hours 6 and 24, 1528 and 1924 metabolites respectively were differentially regulated with statistical significance. At hour 6, linoleic acid metabolism was again the most affected pathway. At hour 24, D-glutamine and D-arginine pathways were the most affected. Comparing all burned animals to all sham animals, 728 metabolites were differentially regulated. Pathways containing a significant number of these common elements include arachidonic acid, starch and sucrose metabolism.ConclusionsThermal injury induces changes in the metabolome of mice that are evident in skin biopsies. The continual involvement of the arachidonic acid pathway highlights the inflammatory process that occurs in the 24 hours after burn injury. The common changes in starch and sucrose metabolic pathways reflects the hypermetabolism that results from burns. The dynamic process of burn injury response is revealed in the variability of differentially regulated metabolites at each time point. Further, the pathways most affected at hour 24 differ from those at the earlier time points, which are more closely associated with inflammation.Applicability of Research to PracticeFuture research will determine the potential of using skin biopsies in human patients after thermal injury to investigate metabolomic changes. Early recognition of these alterations may help influence clinical interventions to promote appropriate inflammatory response and long-term healing.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.292
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 479 Vaccum-Assisted Closure Therapy in Split-Thickness Skin Graft on the
           Wound on the Contours of the Body
    • Authors: Pyo S; Joo H.
      Abstract: IntroductionFor successful skin grafting, contact between the graft and the wound bed is important. To promote close contact between the graft and the wound, a splint or bolster dressing was applied to the graft site. However, the splint could not be fit into wound on the contours of the body. Patients complained about the use of splint due to their inconvenience. Therefore, we present the method of a vacuum-assisted closure (VAC) therapy, a replacement for the use of a splint on the graft site, that can improve graft survival rate on wounds on the contours of the body.MethodsThrough a chart review, we studied medical records from January 2014 to July 2017. Wounds on the contours of the body of 106 patients were healed with VAC therapy following skin graft. The data was collected for characteristics such as age, sex, size of wounds, and underlying disease, complications.ResultsAmong 106 patients, there was 1 patient for face, 2 for neck, 6 for anterior chest, 1 for shoulder, 2 for axilla, 1 for back, 8 for arm, 3 for hand, 1 for sacrum, 3 for buttock, 2 for trochanter, 9 for thigh, 27 for lower leg, 43 for foot. There were 4 patients for active bleeding, 5 for minor hematoma, 2 for partial graft loss.ConclusionsVAC therapy reduced graft loss and improved graft success rate due its close contact ability. The patient was satisfied with the ease of dressing and handiness. In addition, patients and medical staff have satisfactory results due to increased mobility during hospitalization.Applicability of Research to PracticeThis research attempted to report the utility of performing negative pressure wound therapy in parallel with skin grafting on the wounds on the contours of the body, which are difficult to care for by applying a splint and the existing dressing treatment.Table 1.Clinical characteristicsMode of injury (patients number)Total (n=106)Scalding burn60 (56.6%)Contact burn20 (18.9%)Flame burn8 (7.5%)Electrical burn5 (4.7%)Chemical burn1 (0.9%)Pressure sore4 (3.8%)Skin defect6 (5.7%)Burn scar contracture2 (1.9%)
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.373
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 121 Risk Factors for Acute Stress Disorder and Post-Traumatic Stress
           Disorder in Burn Survivors
    • Authors: Wiktor A; Carmichael H, Staubli L, et al.
      Abstract: IntroductionPost-traumatic stress disorder (PTSD) and acute stress disorder (ASD) occur in 25–40% of burn survivors. ASD is diagnosed within 30 days of the inciting trauma, while PTSD is diagnosed after 30 days. A gap in knowledge exists in identifying modifiable risk factors that could be targeted to reduce the occurrence of these disorders. This project sought to determine the incidence of ASD and PTSD in burn survivors, and to define the potential risk factors for the development of ASD and PTSD.MethodsA retrospective cohort study reviewed all patients admitted with burn-related injuries who were screened for ASD/PTSD from July 2015 to June 2018 at our ABA-verified burn center. Data recorded included: basic demographics, burn etiology, percent total body surface area (% TBSA) burned, pre-existing psychological diagnosis, prior substance abuse, urinary toxicology (Utox), length of stay (LOS), number of operations, need for mechanical ventilation, and major complications. Univariate analysis was performed utilizing chi-square and Mann-Whitney’s U-tests. Multivariate logistic regression analysis was then performed in a step-wise manner.ResultsASD and/or PTSD screens were performed on 522 patients. Of these, 479 (91%) underwent an ASD screen, 202 (42%) underwent both ASD/PTSD screens. Baseline demographics included: median age 42 years (range 16–90), male 339 (71%), median %TBSA burned 4.0 (range 0.1–83%). Patients with positive ASD screens were more likely to be female (39% vs 26%, p=0.01), history of psychiatric illness (50% vs 20%, p<0.01), history of substance abuse (51% vs 39%, p=0.03), and positive Utox screen for stimulants (25% vs 16%, p=0.05). Patients with positive PTSD screens were more likely to have a larger %TBSA burn (8% vs 5%, p=0.05), longer LOS (20 vs 12 days, p=0.01), need for mechanical ventilation (26% vs 11%, p=0.01), and the occurrence of one or more major complication (62% vs 11%, p<0.01). Of the patients with a positive ASD screen, 66% (n=36) developed a positive PTSD screen; all of these patients were mechanically ventilated (p=0.03). On multivariate analysis, significant risks for positive PTSD screen were: ASD positive screen (OR 18.5, p<0.01), history of substance abuse (OR 4.25, p=0.02), and LOS (OR 1.03, p<0.01). In contrast, a positive Utox for marijuana was associated with a reduced risk of positive PTSD screen (OR 0.17, p=0.01).ConclusionsRisk factors for developing PTSD include a positive ASD screen, history of substance abuse, LOS, and need for mechanical ventilation. Marijuana use at the time of injury may confer a protective effect.Applicability of Research to PracticeTargeting specific risk factors may impact ASD/PTSD occurrence. Further research is required.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.122
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 438 Child Abuse Rates Among Genital Burn Victims Significantly Higher than
           in Unstratified Pediatric Burn Patients: An Aggregate Data Analysis
    • Authors: McCarthy M; Chernobylsky D, Chaffin A.
      Abstract: IntroductionPediatric burn patients that are victims of child abuse is a serious concern in our society today. Unfortunately, while existing literature describes the rates of child abuse in pediatric burn patients, no literature exists comparing the rates of child abuse in burn victims stratified by genital burns. Our objective was to analyze the literature regarding whether the rate of child abuse in genital burn patients is significantly different from unstratified pediatric burn patients.MethodsTerms “genital burns” with “child abuse” were searched through PubMed, Ovid, and Embase. 10 articles from the available 221 were selected based on pertinence. Exclusion criteria involved studies that did not define number of genital burn victims or patients over 18 years old. In the studies, patients were similar in age and distribution of burn types. Data was collected & aggregated to calculate percent child abuse among pediatric burn patients, which was then compared to a recent, 35-year epidemiologic study of child abuse among unstratified pediatric burn patients with similar age (avg). Statistical analysis was performed via a Comparison on Proportions [N-1] Chi-Squared Test.ResultsThe aggregated data showed that 153/387 pediatric genital burn patients were victims of child abuse (39.5%) while 403/5,748 unstratified pediatric burn patients were child abuse victims (7%). The analysis showed a significantly higher rate of child abuse among patients stratified by genital or perineal injury than unstratified pediatric burn patients (39.5% vs 7%, P < 0.0001).ConclusionsWhile the rates of child abuse are low among pediatric burn patients overall, the rates are significantly higher when pediatric burn patients are stratified by genital burns from the existing literature. This review of the literature also showed that pediatric patients with genital burn injuries were more likely to have deeper burns requiring skin grafting & had trends for higher rates of complications and mortality. However, due to the limited data available in existing literature, further studies are warranted to aid in the development of more precise screening and assessment guidelines for child abuse within this specific, at-risk patient population.Applicability of Research to PracticeThis is a vital consideration for practicing physicians as it suggests a higher index of suspicion for child abuse, especially among this at-risk population that is already often underreported.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.334
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 239 Intraoperative Liposomal Bupivacaine for Skin Graft Donor Site
           Analgesia
    • Authors: Artz C; Ward Jr M, Miles M, et al.
      Abstract: IntroductionBurn injury and subsequent reconstructive operations often result in severe pain. Pain at the skin graft donor site is often more intense than the burn site itself. Traditionally-used local anesthetics administered intraoperatively can provide effective pain control at graft sites, but the duration of action of these agents is short. Liposomal bupivacaine (LB) is a novel local anesthetic contained within multiple, non-concentric lipid bilayers to prevent rapid elimination. The formulation provides a novel, sustained-release analgesia to prevent postoperative pain for up to 72 hours. The primary aim of the study was to describe the efficacy of LB for postoperative donor site pain control for patients undergoing skin graft procedures.MethodsA retrospective review was performed of adult patients at a regional burn center who received full and split-thickness skin autografts with intraoperative donor site LB field block from January 2017 to February 2018. Adults with burn, traumatic, and chronic wounds were included. Patients were asked to rate donor site pain on a 1 to 10 scale at 24 hours and 48 hours postoperatively. Patients were also asked whether the donor or graft site was more painful. Adverse events were tracked including surgical site infection and 30-day readmission.ResultsTwenty-seven patients (30 donor sites total) met inclusion criteria. Three patients had two donor sites which were included. Median burn size was 4 (1–7) percent total body surface area (%TBSA). Median donor size was 70 (22.5–252) cm2. Donor site locations included anterior thigh (27), posterior torso (1), left arm (1), and anterior torso (1). Four full and 26 split-thickness autografts were included. Median dose of LB used was 266 mg. Ninety percent of patients (27 of 30) rated donor site pain as 3 or less 48 hours after surgery. Eighty percent of patients (24 of 30) stated donor site pain was less than graft site pain. One patient experienced a donor site infection which was successfully treated with antibiotics. One patient was readmitted within 30 days. All donor sites were re-epithelialized by post-operative day 14.ConclusionsPatients who received intraoperative LB reported less postoperative donor site pain than expected without any major complications of LB administration identified. This preliminary data suggests that LB is not only safe, but also appears to be a promising agent for prolonging postoperative analgesia and minimizing donor site pain in patients undergoing skin graft procedures.Applicability of Research to PracticeLiposomal bupivacaine may prolong post-operative analgesia in patients with painful skin graft donor sites.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.165
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 338 Thrombolytic Salvage of Threatened Frostbitten Extremities: A
           Systematic Review
    • Authors: Drinane J; Kotamarti V, Nair L, et al.
      Abstract: IntroductionFrostbite is a freezing cold weather injury that results in soft tissue loss and can lead to amputation in severe cases. Vascular thrombosis following injury causes ischemic tissue damage. Threatened extremities may be salvaged with thrombolytics to restore perfusion. The authors performed a systematic review to determine if thrombolytic therapy is effective and to identify patients who may benefit from it.MethodsPubmed, EBSCO and Google Scholar were queried using the key words “thrombolytics”, “frostbite”, “fibrinolytics” and “tPA”. Studies written after 1990 in English language journals met inclusion for criteria. Exclusion criteria were failure to delineate anatomic site of injury, failure to report number of limbs salvaged, animal studies and non-English language publications. Thrombolytic therapy was defined as intra-arterial or systemic IV administration of tPA, alteplase, urokinase, streptokinase or any tPA derivative. Subgroup analysis when possible was performed for upper extremity injuries given the greater functional implications of an upper limb injuryResultsA total of 42 studies were identified from our search. 19 studies satisfied criteria for inclusion in the systematic review. 17 studies were retrospective cohort studies, and two were case studies and one was a randomized, controlled trial. A total of 1731 extremities and digits in 396 patients were treated with thrombolytics and 428 amputations were performed. 457 upper extremities and upper digits in 189 patients were treated with thrombolytics and 83 amputations performed. Angiography was performed in cases of severe frost bite, and thrombolytics were administered when perfusion was compromised. The most common means of thrombolysis was catheter directed tPA and heparin. Less commonly, intravenous administration of thrombolytics was reported in two studies. The most common duration of therapy was 24 hours. Limb salvage rates ranged from 47% to 100% with a weighted average of 78.3%. For upper extremities and upper digits the limb salvage rate ranged from 0% to 100% with a weighted average of 78.%.ConclusionsFrostbite is a thermal injury distinct from burns and the treatment is different. Severely frostbitten limbs can be salvaged with thrombolytics. Thrombolytics are beneficial and prevent amputation and salvage digits and limbs that would otherwise be amputated. Given its efficacy, expanded use of thrombolytics in severe frost bite may be warranted due to its efficacy. However, more research is warranted to determine the ideal treatment of frostbite.Applicability of Research to PracticeThis study demonstrates that while thrombolytics is experimental, if more widely adopted has the potential to save many frost bitten limbs that would otherwise be amputated.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.249
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 76 Nebulized Epinephrine Attenuates Lung Alveolar and Interstitial Edema
           Compared to Phenylephrine and Albuterol in Ovine Burn and Smoke
           Inhalation-Induced Acute Lung Injury
    • Authors: Fukuda S; Lopez E, Niimi Y, et al.
      Abstract: IntroductionSmoke inhalation-induced acute lung injury (ALI) increases the mortality of burn patients up to 60%. The severity of ALI is associated with lung alveolar/interstitial edema and airway mucosal hyperemia. This study was aimed to test the hypothesis that nebulized epinephrine (EPI: non-specific adrenergic receptor [AR] agonist) more effectively ameliorates the severity of burn and smoke inhalation-induced ALI than nebulized phenylephrine (PE: α-1 AR agonist), and albuterol (ALB: β-2 AR agonist).MethodsThe injury was induced in 46 female sheep by 40% TBSA, 3rd° burn and 48 breaths of cotton smoke inhalation under anesthesia and analgesia. Post-injury, sheep were mechanically ventilated and monitored for 48 hrs in a conscious state. Cardiopulmonary hemodynamics, blood gases, and lung lymph flow were measured every 6 hrs. Pulmonary edema was assessed by measuring pulmonary vascular permeability index (PVPI) and lung wet-to-dry weight ratio (W/D) and airway mucosal edema was assessed by trachea W/D. Sheep were randomly allocated to 4 groups; 1) EPI, 4 mg, n=11; 2) PE, 10 mg, n=6; 3) ALB, 6.6 mg, n=12; and 4) Control, n=17. The AR agonist nebulization began 1 hr post-injury and repeated every 4 hrs thereafter.Results65 % of control and 75 % of ALB sheep survived for 48 hrs, while 100 % of sheep survived in EPI and PE. The EPI significantly improved PaO2/FiO2 ratio and oxygenation index compared to other groups (12 - 48 and 30 - 48 hrs, respectively). The EPI significantly reduced PVPI compared to control and ALB (18 - 30 and at 36 hrs, respectively) and lung W/D was significantly less in EPI compared to control and ALB. Also, EPI and PE significantly reduced trachea W/D compared to control. The EPI significantly reduced alveolar edema and bronchial obstruction scores in histopathology compared to control. Total urine output and net fluid balance were significantly improved in both EPI and PE compared to control and ALB (at 48 hrs and 36 - 48 hrs, respectively). No adverse effects were observed in all drug group.ConclusionsOur data suggest that both local airway alpha-1 and beta-2 agonists effects are critical in attenuating airway mucosal and lung edema and improving pulmonary function. The nebulization of EPI may be considered as an early care of burn patients with smoke inhalation-induced ALI.Applicability of Research to PracticeThe results are highly translational to the clinical practice.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.078
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 390 CCL2/CCR2 Signaling Axis Involving Activated Monocyte-Derived
           Macrophages Causes Spinal Cord Neuroinflammation and Nerve-Motor Pathology
           after Burn Injury
    • Authors: Khan M; Mostafa F, Yasuhara S, et al.
      Abstract: IntroductionInfants and young children with major burns suffer with burn-induced systemic inflammation (BISI) and are at high risk of mortality. BISI triggers activation and migration of monocyte-derived macrophages (MD-MΦ). Migration of activated MD-MΦ in the spinal cord can cause neuroinflammation, affecting integrity of motor neurons and nerve-motor function. However, the migration of activated MD-MΦ through the CCL2/CCR2 axis and their effects on neuroinflammation in the spinal cord, leading to motor neurons damage and neuromotor dysfunction after burn injury have not been determined yet.MethodsWild type (WT) and NEF-EYFP mice were used to produce ~25-30% scald burn injury for 1, 7 or 21 days. Cytokines were analyzed by Cytokine Antibody Array. Motor neuronal apoptosis in the spinal cord was identified by TUNEL assay. Nerve termini disintegration in NEF-EYFP mice were analyzed by fluorescent microscopy. Muscle strength in mice was determined by Hanging Wire Test.ResultsOur results showed that CCL2 release was significantly increased in the serum (> 2.3 folds) and in OSE (> 2 .4 folds) after burn injury and Ex-His insult, respectively, compared to respective controls. Migration of CCR2-containing MD-MΦ was higher in burned mice, as demonstrated by CCR2 positive cells, than in the sham burned mice. Depletion of MD-MΦ by Clophosomes prevented their migration to the spinal cord. TUNEL assay showed an increase in apoptotic cells and a decrease in EYFP neurons in the spinal cord, suggesting that the motor neuronal cells in the spinal cord were lost by apoptosis compared to non-burned mice. Microscopy showed that the nerve termini at neuromuscular junction were disintegrated after burn injury. Analysis of muscle strength by hanging wire test showed that the latency to fall was increased significantly in BISI (0.86 + 0.8 min) compared to sham burned (1.65 + 0.8 min) mice.ConclusionsCollectively, our results suggest CCL2/CCR2 signaling axis may be responsible for neuroinflammation in the spinal cord, which could lead to motor neuronal damage-associated neuromotor dysfunction. Thus, CCL2/CCR2 signaling axis involving MD-MΦ after burn injury would help us develop therapeutic measures to treat burned children.Applicability of Research to PracticeDissecting the molecular and cellular mechanisms of neuroinflammation in spinal cord would benefit in clinical settings to understand burn pathology of the spinal cord.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.291
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 290 Improving International Burn Care: a Collaborative Institutional Model
    • Authors: Gibson C; Gallagher J.
      Abstract: IntroductionIn 2012, we performed an evaluation and feasibility study to determine the need for burn care in the Lake Zone of Tanzania, which serves a population of more than 15 million people. From that study, it was determined that there was an unmet need for burn care. Through an established academic institutional relationship, as well as an outside 3-year grant, a burn unit was established at the regional referral hospital. The purpose is to the review the current status of the project and highlight progress made in burn care in the Lake Zone.MethodsDocumentation from trips to Tanzania were reviewed as well as the final report generated for the grant. Admission data, both to the hospital and the burn unit, as well as operative logs were obtained directly from hospital records.ResultsThe number of burn patients admitted to the burn unit increased significantly over the observed period: 84 in 2013, 251 in 2014, and 328 in 2015. Over 180 healthcare providers attended a 5-day burn training course. Although the burn unit at the regional hospital is no longer performing surgery, A second 20-bed burn unit opened in December 2014 at the level 1 zonal hospital, where acute burn and reconstructive surgery is now offered. This burn unit is staffed by providers who attended the burn training course. In addition, a 4-bed nursing burn unit in a nearby community hospital opened. So far, in 2018 the burn unit at the level 1 hospital has admitted 85 patients to their burn unit and performed 74 surgeries (35 burn, 29 contracture release, 10 other). Current outreach includes collaboration with both burn centers and improvement in local referral between the two.ConclusionsThrough a modest investment of time and resources the quantity and quality of burn care increased in the region and has endured past the original grant period. The relationship within the institutional partnership continues, with a focus on education, professional development and establishing the first Plastic and Reconstructive Burn Director in Tanzania who will be starting in December 2019.Applicability of Research to PracticeWe hope that our experience in Tanzania will serve as a model for future efforts to improve burn care in other low- and middle-income countries.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.207
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 36 A Novel Polysaccharide Derivative to Enhance Wound Healing in
           MRSA-Infected Porcine Partial-Thickness Burn Wound Model
    • Authors: Egro F; Repko A, Kim D, et al.
      Abstract: IntroductionMethicillin-resistant Staphylococcus aureus (MRSA) is the most common etiology of wound infection in the US, leading to considerable morbidity and mortality. SYN01 is a non-toxic, polycationic polysaccharide which disrupts biofilms and prevents bacterial colonization in vitro. It is low cost, stable at room-temperature, and not associated with bacterial resistance. The aim of this study was to investigate the therapeutic potential of SYN01 in MRSA-infected porcine partial-thickness wounds (PTBWs).MethodsA total of 4x4cm 30 PTBWs were created on two female Yorkshire pigs and were infected with approximately 108 CFU of MRSA (ATCC® BAA-1717™) on Day 2. Wounds were given 3 days for infection to develop. Starting post-burn day 5, each wound was assigned to one of three treatment groups (n=10 each): no treatment, silvadene (silver sulfadiazine, standard of care), SYN01 rinse and gel. Dressing changes were performed 3 times a week and punch biopsies were taken at each dressing change for bacterial counts using blood-agar plates. Pigs were sacrificed on post-burn day 28. Measured outcomes included percentage of wound closure, bacterial counts and histology.ResultsSYN01 topical application lead to a statistically significant wound healing improvement in MRSA-infected partial-thickness burn wounds compared to silvadene treatment and no treatment after day 5 (Figure 1). Application of SYN01 reduced the bacterial count however no statistical significance was reached. Histological wound examination of POD28 demonstrates that wounds treated with SYN01 have healed markedly and are comparable to the healing quality of non-infected burn wounds.ConclusionsSYN01 significantly enhances wound healing in MRSA-infected PTBWs and leads to optimal histological morphology.Applicability of Research to PracticeSYN01 enhances wound healing in PTBWs and is a promising therapeutic option for treating and preventing PTBW infections.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.040
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 525 Clinical Impact of Cryopreservation on Split Thickness Skin Grafts in
           the Porcine Model
    • Authors: Holzer P; Lellouch A, Leto Barone A, et al.
      Abstract: IntroductionHuman cadaveric allografts are the gold standard for temporary coverage of severe burns, but the supply is limited due to a paucity of clinically acceptable donors and onerous processing requirements. Porcine skin shares fundamental properties with human skin; thus live-cell porcine xenografts represent a potential alternative to achieve temporary coverage of severe burns. Previous research demonstrated that genetically-engineered, knock-out porcine grafts, which lack α-1,3-galactose sugar responsible for hyperacute rejection observed in wild-type xenografts, provide an equivalent barrier and adherence function as allografts in primate models. However, little data exists on the impact of extended cryopreservation on such grafts. In this study, we examined the impact of long-term cryopreservation on graft viability, graft take, and barrier function in a preclinical model.MethodsOver a 7-year period, over sixty porcine split thickness skin grafts were cryopreserved and stored at -80oC. Cellular viability of stored grafts was assessed using formazan-MTT and phenyl acetate assays to quantify mitochondrial activity. Stored grafts were compared to fresh skin grafts (100% viability) and heat denatured controls. To test for biological properties, grafts cryopreserved for varying lengths were grafted on swine recipients. Each swine (n=4) received 4 grafts: one autograft and three allografts of identical MHC-profiles. Grafts were clinically assessed every other day postoperatively for overall graft-take, adherence to wound bed, and time until complete graft rejection. The rejection sequelae was observed and assessed histologically via a blinded-pathologist based on the BANFF grading scale.ResultsThere were no technical failures; all grafts initially adhered to their respective wound beds and re-vascularized. On POD 8, fresh and frozen autografts were indistinguishable on gross examination. Allogeneic grafts appeared comparable to autografts through POD 4. However, by POD 8, all allogeneic grafts, fresh and frozen, demonstrated mild erythema, consistent with rejection and were considered fully rejected by POD 10. In contrast, autografts, remained warm, viable, and appeared healthy. The authors found no statistically significant difference in the duration or quality of adherence among the comparator groups. Similarly, cellular viability (mitochondrial activity) was comparable.ConclusionsRelative quantitative viability and mitochondrial activity of fresh, recently preserved and long-term preserved skin grafts were comparable.Applicability of Research to PracticeThe results of this study offer the potential for tissue banking for longer periods. This would be beneficial both in preparation for mass casualty events and to address global shortages.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.414
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 120 Muscle Homeostasis is Disrupted in Burned Adults
    • Authors: Clark A; Song J, Yao X, et al.
      Abstract: IntroductionSevere burn leads to substantial skeletal muscle wasting associated with adverse outcomes and protracted recovery. Signal pathways that regulate apoptosis, myogenic proliferation and differentiation are incompletely understood and have not been studied in adult burn patients. The purpose of the study is to investigate muscle tissue homeostasis in response to severe burn.MethodsMuscle biopsies from the right vastus lateralis muscle were obtained from 10 adult burn patients at the time of their first operation. Patients were grouped by burn size (TBSA <30% vs. TBSA ≥30%). Muscle fiber size was measured on histology and factors of cell death and muscle regeneration were examined by cytokine analysis and Western blot.ResultsThere were five adult burn patients in both the small burn and large burn group. There were no differences in age, gender, BMI, or time to biopsy. Muscle cell cross sectional area was significantly different between the burn groups (small 3687.0 ± 527.2 µm2 vs. large 2174.3 ± 183.8 µm2 p = 0.040, Figure 1). Cytokines IL-8 (small 58.0 vs large 388.7 pg/mL, p = 0.057) and IL-10 (small 7.53 vs. large 37.3 pg/mL, p = 0.059) trended higher in the larger burn group, but did not reach statistical significance. Expression of ubiquitin E3 ligase Murf1 and cell death downstream effector Caspase3 were increased in the large burn group (p < 0.05). No statistically significant difference was seen between groups in expression of the myogenic factors Pax7, MyoD, or myogenin. Pax7 and PCNA expression in muscle tissue significantly correlated to injury severity in the smaller burn group (p < 0.05).ConclusionsAdult patients with large burn (>30%) have decreased muscle cell cross sectional area, and increased circulating Caspase3 and Murf1 when compared to patients with small burn. Muscle atrophy after burn is driven by apoptotic activation without an equal response of satellite cell activation, differentiation, and fusion.Applicability of Research to PracticeA better understanding of the mechanisms behind the imbalance of muscle cell loss and regrowth may contribute to therapeutic advances to improve the morbidity associated with muscle atrophy after burn.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.121
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 478 Complex Burn Reconstruction with Venous Flaps
    • Authors: Odobescu A.
      Abstract: IntroductionVenous flaps were introduced in 1981 by Nakayama et al., however, they have not gained acceptance in mainstream microsurgery as a reliable method of reconstruction. To our knowledge, venous flaps have not been previously used in burn reconstruction.MethodsSeven shunt-restricted venous flaps were performed to reconstruct primary or secondary burn defects in six patients. Five of these flaps were used to cover acute burn defects with exposed joints, tendons or nerves. Two flaps were used for scar contracture release of the first web space and wrist. Donor sites included the volar forearm or medial calf. Flaps ranged in size from 24 cm2 to 54cm2 with an average size of 36 cm2. The inflow vein was chosen retrograde in all but one case, while all the venous outflow was antegrade.ResultsWe experience one complete flap loss out of the six flaps due to arterial insufficiency/thrombosis. The remaining flaps had complete survival with excellent functional and cosmetic outcomes. One flap developed a superficial infection resulting in partial dehiscence that healed with dressing changes and antibiotics. Donor site complications included partial skin graft loss in one patient.ConclusionsOur experience with the use of venous free flaps in complex upper and lower extremity reconstructions has produced excellent cosmetic and functional results. We continue to refine flap design to ensure maximal flap survival and minimize donor site morbidity.Applicability of Research to PracticeVenous flaps can be a powerful tool in the microsurgical armamentarium for upper and lower extremity burn reconstruction.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.372
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 237 Safety of Oxandrolone Administration in Severely Burned Adults
    • Authors: Hundeshagen G; Tapking C, Ziegler B, et al.
      Abstract: IntroductionSevere burn injury causes severe muscle protein catabolism, contributing to impaired wound healing and general weakness. Oxandrolone is an anabolic agent that has been proposed to ameliorate muscle wasting in severely burned children. The efficacy of oxandrolone to promote muscle protein kinetics has been shown; the aim of this study is to assess its safety and side effects in adult burn patients.MethodsIn a retrospective review, patients were identified who received 10mg Oxandrolone (OX) twice daily after burn injury and a control group of patients (CTR) was matched based on age, sex, and total body surface area (TBSA) burned. Complete liver panels (AST, ALT, alkaline phosphatase (AP), bilirubin, cholinesterase, albumin, prothrombin time(PTT)) were measured before and after administration of OX and compared intraindividually and between OX and CTR. Side effects of OX were recorded.ResultsTen OX recipients were matched to 10 CTR. The groups were comparable in age (OX: 35±4, CTR:39±6, p0.4), sex and TBSA burned (OX: 59±6% CTR: 55±5%). There were no increases in parameters indicative of hepatic toxicity after treatment with OX (GOT, GPT, bilirubin, cholinesterase, albumin); AP and PTT were significantly reduced intraindividually after treatment with OX (AP: 144.5±25.7 to 99.8±18 U/l, p=0.015, PTT: 31.3±2 to 27.8±1.9 s, p=0.002) and when compared to CTR, but remained within normal range. No patient in the OX group progressed to clinically significant liver dysfunction; no hirsutism was observed.ConclusionsOxandrolone may be a safe anabolic agent in severely burned adults to support amelioration of severe muscle wasting. No negative short term effects or hepatic toxicity could be observed in this study.Applicability of Research to PracticeThis study may aid in providing evidence for the safety of oxandrolone in severely burned adult patients in order to facilitate larger, prospective multicenter trials to prove its positive effects in this population in terms of improved anabolism, rehabilitation and scar formation.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.164
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 437 The Relationship Between County Income Levels and Burn Fatality Rates
    • Authors: Miotke S; Mohr W.
      Abstract: IntroductionDeath rates from burn injury have improved greatly over the past several decades, owing in large part to improvements in fire protection technology and building code enforcement. In our state, fire deaths decreased steadily from the 1970s to the 2000s. However, in 2017, there was a 58% increase in the fire death rate from the previous year, resulting in the highest number of deaths since 1995. State Fire Marshal data were analyzed to glean insight into recent trends and the potential correlation with county income levels.MethodsThe State Fire Marshal Annual Reports for 2013 - 2017 were reviewed individually and in aggregate. These data were paired with United States Census county population and median income data to determine the potential correlations between county income, fire rates and fire death rates.ResultsState records revealed 211 deaths from fires from 2013 - 2017. The state fire death rate over that timeframe was 0.78 per 100,000 people. Among the 18 counties with death rates twice that of the state level, 12 (67%) had median income levels in the bottom 50thpercentile of the state and eight (44%) had levels in the lowest quartile. In 2017, 22 counties had fire death rates above the state average. Ten of these counties (45%) were among the lowest quartile of median income. These counties tended to suffer fires more frequently, with five (50%) having fire rates in the top quartile. In 2017, the fire rate of counties in the lowest quartile of income was 1.6 times that of counties in the upper three quartiles. The fire death rate of counties in the lowest quartile of income was 5.6 times that of counties in the upper three quartiles. All counties in the lowest quartile of median income were outside of the state’s metro area.ConclusionsDespite nationwide advancements in burn mortality and shared access to verified burn centers, there remain, even at the state level, outcome differences which correlate with county income. The increased burn death rate in 2017 was distributed at the same level of income disproportionality as prior years. The increased frequency of fires in poorer counties does not sufficiently account for the increased rate of fire mortality.Applicability of Research to PracticeThe determination of risk factors for burn injury and mortality is essential for maximizing injury preventative resource allocation. Efficient targeting of burn prevention resources should include lower-income, rural counties.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.333
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 337 New Technologies for Precision Repair of Refractory Wounds Post Burn
           and Trauma
    • Authors: Shen C.
      Abstract: IntroductionRefractory wounds refer to those very complicated wounds which are difficult to repair only with conventional dressing and surgery, including extensive deep burn wounds, acutely devastated wounds post trauma, and chronic refractory wounds. Such wounds affect 50 million people every year in our country, contributing to fairly high morbidity and mortality rates. Hence, the study on prevention and treatment of refractory wounds seems to be necessary.MethodsWe investigated more than 200,000 patients from 300 burn centers across our country to find how to regulate the wound microenvironment. We innovated the methods and materials for developing functional hydrogels and built a humid and breathable wound microenvironment. We innovated gene vector materials, constructed functional epidermal cells, and developed a cell-particle skin graft technology. We were the first to develop the platelet-rich plasma (PRP) gel technology and obtained the product certificates. We improved the PRP technology, increasing the preparation efficiency by more than 20 times with merely a 1% cost compared with conventional methods. We invented the second and third generations of negative pressure wound therapy (NPWT) system featured by lavage and brace functions respectively.ResultsWe found that the microenvironment of refractory wounds was abnormal, including poor drainage, blood-flow disorders, inflammation, infection and degenerative tissues. On this basis, we developed a new comprehensive treatment plan. The survival rate of extensive burn patients was greatly improved, and the healing time of thick split skin donor sites was shortened from 20 days to 4 days. Acutely devastated wound repair was improved significantly, and the secondary damage to the donor site of skin flap was remarkably reduced because of the significant reduction in the rate of skin-flap usage. With the comprehensive treatment, the length of hospital stay in patients with pressure ulcers and diabetic foot was significantly curtailed, and the mortality rate of some special diseases, such as deep sternal incision infections (DSII) and necrotizing fasciitis (NF), was minimized.ConclusionsThe new comprehensive treatment plan can greatly improve the microenvironment and the quality of treatment in refractory wounds post burn and trauma, which has been applied in more than 1,000 hospitals where over 500,000 patients have been treated.Applicability of Research to PracticeOur new comprehensive treatment plan developed based on our findings has been applied in clinical practice by over 1,000 hospitals in our country and more than 500,000 patients have been successfully treated. This clinical research is completely applicable to medical practice.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.248
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 389 Limited Volume Resuscitation with 5% Albumin Exacerbates Liver Injury
           in a 40% TBSA Swine Burn Model
    • Authors: Gomez B; Chao T, Little J, et al.
      Abstract: IntroductionAcute burn care (>30% TBSA) requires IV resuscitation with large volumes of fluids. Lactated Ringer’s (LR) is the most commonly utilized fluid however, other crystalloids (PlasmaLyte; PL) and colloids (fresh frozen plasma [FFP]; 5% Albumin [ALB]) have been suggested. While resuscitation maintains hemodynamics, limited volumes may suffice in resource-poor environments or mass casualty scenarios. This study compares limited IV resuscitation to the modified Brooke (MB) formula, with emphasis on liver function.MethodsThirty anesthetized swine were subjected to 40% TBSA contact burns and randomized to one of five groups (n=6/group): 15mL/kg/d with LR; PL; FFP; ALB; was compared to 2ml/kg/%TBSA LR (MB). Animals recovered in metabolic cages for urine and blood collection (baseline (BL), 6, 12, 24, 32, and 48h post-burn) to quantify biochemical markers. Following euthanasia (48h) liver tissue samples were snap frozen for analysis. Four non-thermally injured animals (sham) served as tissue controls.ResultsPlasma protein was elevated at 48h with colloids (p≤0.002) and albumin levels were elevated throughout the study in the ALB group (p<0.0001). When compared with BL levels, liver enzymes alanine (68.3±1.3 vs 84.0±2.9 mg/dL; p<0.0001) and aspartate (31.0±1.0 vs 90.2±4.3 mg/dL; p<0.0001) aminotransferases were elevated by 6h post burn and remained high regardless of treatment. In the ALB group levels of bilirubin (p<0.0001) were higher throughout the course of the experiment when compared with all other treatments. Total urine output was greater in animals receiving MB (1703±245 mL) when compared with LR (1050±61 mL; p=0.07), PL (797±160 mL; p=0.007), and ALB (933±160 mL; p=0.09), but not FFP (1330±181 mL; p=0.61). Caspase was significantly up regulated in MB, LR, PL, and ALB when compared with sham animals (p≤ 0.019). Heat shock protein 70 tended to be greater in MB and L-LR than sham animals (p≤0.066). Histology revealed reduced intracellular glycogen reduced due to burn (p≤0.01) and a significantly higher level of edema in ALB when compared with other treatment groups (p≤0.16) as demonstrated by histology.ConclusionsResults from these experiments suggest that in this model, resuscitation with ALB early post-burn negatively impacts liver function. No abnormal changes in liver damage markers were detected in animals receiving FFP. Data from these studies can help inform limited volume resuscitative efforts for patients with burns.Applicability of Research to PracticeLimited IV fluid resuscitation is common in resource poor environments. Any available IV fluid would be effective to buy time in prolonged field care, however physicians should monitor liver function if using ALB.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.290
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 35 Sildenafil Prevents Adverse Cardiac Remodeling and LV Dysfunction in an
           In Vivo Model of Burn Injury
    • Authors: Wen J; Radhakrishnan G, Cummins C, et al.
      Abstract: IntroductionBurn-induced cardiac dysfunction is a significant contributor to morbidity and mortality after burn injury. The cGMP/PKG axis modulates the contraction and relaxation of cardiac myocytes, while PDE5 may contribute to stress- induced cardiac remodeling. We utilized a well-established model of cutaneous burn injury to assess the role of PDE5 inhibition in control of burn-induced heart dysfunction.MethodsSprague Dawley rats had 60% TBSA scald burn and were treated with sildenafil (SIL, 20 mg/kg) immediately after burn. Rats were harvested at 24 hours post-burn (24 hpb). The techniques used in this study included Vevo2100 Transthoracic echocardiography, ELISAs, histology and qPCR.ResultsThe PKG activity was decreased by 1.6-fold and PDE5 mRNA expression was increased by >3-fold in the myocardium of burned (vs. normal) rats. The stroke volume, cardiac output, and ejection fraction, were decreased by 21%, 15% and 20%, respectively, in burned/untreated rats. SIL treatment restored normal levels of PKG activity and PDE5 expression in the myocardium of burned rats, and subsequently, LV systolic function (SV, CO, EF) was preserved in burned/SIL-treated rats, when compared to burned/untreated rats. Burn/untreated rats had fractional shortening and LV posterior wall thickness (LVPW) decreased by 24% and 23% respectively. Sildenafil treatment restored these to normal levels. Additionally, LV volume in systolic was increased by 132% in burned rats. The significant improvement in LV volume in burned/SIL-treated rats was also observed. Histological and molecular analysis of the myocardium showed that the collagen deposits were increased by >12-fold and associated with 9.3–9.75 fold increase in collagen (COLI and COLIII) expression, 4.4–4.9 fold increase in Natriuretic peptides (ANP and BNP) expression, and 13.8-fold increase in actin, alpha 1, skeletal muscle (aSMA) in burned (vs. normal) rats. SIL treatment resulted in near normal levels of collagen and normalization of the expression levels of collagen (COLI and COLIII), Natriuretic peptides (ANP and BNP) and actin, alpha 1, skeletal muscle (aSMA) mRNAs in the burned myocardium.ConclusionsThis study suggests that short-term treatment with SIL maintained the PDE5-PKG balance and provided cardio-protective effects through reversal (or inhibition) of adverse cardiac remodeling in burned rats. SIL therapy was useful in controlling the LV dysfunction via PDE5/PKG pathway after burn injury and may represent a novel method to reverse burn induced cardiac dysfunction.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.039
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 75 Inhibition of GRK2 Suppressed TNFα-Induced Inflammatory Signaling and
           Pro-Fibrotic Factor in Cardiomyocytes
    • Authors: Wang X; Cummins C, Zhu M, et al.
      Abstract: IntroductionTNFα is significantly elevated in burned patients and plays a role in the pathogenesis of cardiac dysfunction. In addition, increased G protein-coupled receptor kinase 2 (GRK2) modulates cardiac dysfunction. Therefore inhibition of GRK2 and TNFα signaling may be a viable option for burn induced cardiac dysfunction. However, the relationship between the two pathways has not been elucidated. In the present study, we explored the effect of GRK2 inhibitor (GRK2-I) on TNFα-induced pro-inflammatory and pro-fibrotic signaling in cardiomyocytes.MethodsH9c2 cardiomyocytes were exposed to TNFα and were treated with or without GRK2-I. Cellular proteins were analyzed with Western blot and immunofluorescence assay.ResultsTNFα treatments dramatically increased pro-inflammatory cytokine MCP1, which plays a major role in myocarditis and ischemia/reperfusion injury in cardiomyocytes. Pre-treatment with GRK2-I inhibited TNFα-induced MCP-1 secretion in dose-dependent fashion. Simultaneously, GRK2-I suppressed TNFα-induced NF-κB activation as evidenced by blocking NF-κB p65 nuclear translocation and inhibiting TNFα-stimulated IκBα phosphorylation and degradation. NF-κB chemical inhibitors abrogated TNFα-induced MCP-1 secretion in H9c2 cells. Our data demonstrated that GRK2-I significantly decreased endogenous and inflammatory stimulator-induced fibronectin expression in H9c2 cells.ConclusionsGRK2-I inhibited TNFα-induced inflammation through the NF-κB pathway and attenuated the expression of pro-fibrosis protein fibronectin.Applicability of Research to PracticeGRK2-I may represent a promising cardio-protective agent for burn patients.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.077
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 289 Reduction of Hospital-Acquired Methicillin Resistant Staphylococcal
           Aureus Bacteremia in a High Volume Adult Burn Center
    • Authors: Modica A; Seetharaman S, Sood G, et al.
      Abstract: IntroductionMRSA bacteremia continues to have an unacceptably high mortality rate. Burn victims are at risk for this infection due to their lack of protective skin barrier and immunocompromised state. Our study aims to quantify the bioburden present in our adult burn intensive care unit (BICU) compared to the other ICUs in our hospital, implement personal and environmental interventions to decrease the BICU bioburden, and evaluate the effect of these measures on the rates of nosocomial MRSA colonization and MRSA bacteremia.MethodsThis study was designed as an interrupted time series model with concurrent controls to examine associations between the interventions taken to decrease bioburden and changes in nosocomial MRSA colonization and MRSA bacteremia rates. Pre and post intervention bioburden analysis with the ATP bioluminescence assay was performed on samples swabbed from five different high touch surfaces within our hospital’s five ICUs (Burn, Surgical, Medical, Cardiac and Neurosurgical). The interventions were performed in the BICU only. From July 2016 to March 2018, the interventions were performed, including: bed rotation with terminal cleaning, UV light disinfection, hand washing with surgical scrub, and single use dressing set-ups. Four weeks were allotted for each intervention before re-swabbing for residual bioburden.ResultsOut of 492 BICU admissions during the pre-intervention phase, 41 (8.33%) had MRSA colonization, 16 (3.5%) became colonized and 8 cases of MRSA bacteremia developed. There were 6,486 admissions to the other ICUs pre-intervention, with 630 (9.71%) already colonized, 48 (0.74%) with acquired colonization, and 3 cases of MRSA bacteremia. Post intervention, out of 208 BICU admissions, 18 (8.65%) patients had MRSA colonization, 5 (2.63%) patients converted to a carrier and 2 developed MRSA bacteremia. In the other ICUs the percentages of patients with colonization and conversion to carrier remained constant and there were 2 cases of MRSA bacteremia.ConclusionsThe BICU had a higher microbial load on ATP bioluminescence compared to other ICUs. The four simple interventions proposed were able to decrease the overall bioburden in the BICU, decrease the incidence of hospital acquired MRSA colonization and, most importantly, decrease MRSA bacteremia in BICU patients.Applicability of Research to PracticeThis study showed four simple interventions that resulted in decrease of hospital-acquired Methicillin Resistant Staphylococcal Aureus bacteremia in a high volume Burn Center. Further multi-center research would be the next step to validate our MRSA-infection prevention protocol.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.206
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 119 Risk Factors Associated with the Development of Transaminitis in
           Oxandrolone Treated Adult Burn Patients
    • Authors: Pape K; Kiracofe B, Gayed R, et al.
      Abstract: IntroductionOxandrolone, an anabolic steroid, has been used in the treatment of severe thermal injury to counteract the hypermetabolic and hypercatabolic process that can occur. Previous studies have shown oxandrolone to increase body mass, promote wound healing, and restore body weight in severely burned patients. One of the most common adverse effects of oxandrolone therapy has been transaminitis, with a reported incidence of 5–15%. Although transaminitis is a common adverse event, little research has been done to identify the risk factors associated with the development of transaminitis. The purpose of this study was to determine the incidence of transaminitis and to identify risk factors associated with the development of oxandrolone induced hepatic transaminitis in adult burn patients.MethodsThis was a multi-center, retrospective risk factor analysis comparing patients with a thermal burn injury (total body surface area [TBSA] >10%) who received oxandrolone therapy with and without the development of transaminitis over a 5-year period. Transaminitis was defined as any aspartate aminotransferase (AST) or alanine aminotransferase (ALT) value >100 mg/dL while on oxandrolone therapy. Secondary outcomes included mortality, length of stay (LOS), and percentage increase from baseline AST/ALT. After univariable analysis, a multivariable logistic regression analysis was performed to identify factors significantly associated with development of transaminitis.ResultsA total of 309 patients met inclusion criteria from 8 burn centers. The cohort were primarily male (72.5%) with a mean age of 46.1 years (±16.8) and mean burn size of 37.3% (±17.5). Transaminitis occurred in 128 patients (41.4%). After multivariable analsysis, younger age [OR 0.90 (95% CI 0.84–0.98)], IV vasopressor use [OR 1.96 (95% CI 1.16–3.29)], and concurrent amiodarone use [OR 2.48 (95% CI 1.08–5.70)] were associated with higher odds of transaminitis. No significant differences were observed regarding mortality (25.8% vs 20.4%, p = 0.11). LOS was longer in patients who developed transaminitis (43 days vs. 38 days, p = 0.02), but when adjusted for age and TBSA percentage in a multivariable model, transaminitis was no longer associated with increased LOS.ConclusionsTransaminitis occurred at a higher rate than previously reported in the literature. Patients who are younger in age and those receiving concurrent IV vasopressors or amiodarone should be closely monitored for the development of transaminitis.Applicability of Research to PracticeFuture research is needed to identify clinical consequences of oxandrolone-induced transaminitis and how transaminitis should be managed.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.120
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 523 Changes in Fibroblast Phenotype and Matrix Turnover in Established
           Scar Tissue
    • Authors: Fear M; Stevenson A, Toshniwal P, et al.
      Abstract: IntroductionScars remain for life and in the case of pediatric patients scar tissue will often grow through puberty, suggesting scar cell phenotype and matrix dynamics are established for life after injury repair. Fibroblasts are known to be the key cell involved in the production of extracellular matrix in normal skin, during wound repair and in scars and fibrotic disease. However, the changes in phenotype and matrix turnover that underpin scar maintenance for life are poorly understood.MethodsWe have investigated cellular and molecular changes in fibroblast phenotype that impact on matrix production and the response to changes in physical properties of the matrix in human cells using single cell sequencing, metabolic tracing and in vitro phenotypic assays. We have also monitored matrix dynamics in established scar and normal skin in vivo to understand how cell phenotype and matrix maintenance are interrelated. Finally we have monitored the impact of changing matrix properties on fibroblast activity.ResultsDifferences in matrix dynamics between normal skin and established scar tissue are observed in vivo. In addition, changes to fibroblast phenotype are observed using single cell RNASeq in scar and fibrotic tissue that appear to underpin changes to matrix production observed. Finally, we also observe that changes in matrix structure Differences in matrix dynamics between normal skin and established scar tissue are observed in vivo In addition, changes to fibroblast phenotype are observed in scar and fibrotic tissue that appear to underpin changes to matrix production. scar/fibrotic tissue are underpinned by changes to fibroblast phenotype. Similarly the changes in matrix structure (physical properties) impacts on fibroblast activity and may be important in maintaining the scar phenotype for life.ConclusionsThis work demonstrates changes to matrix turnover linked to cellular changes in fibroblasts thay may be responsible for the lifetime maintenance of scar tissue. These changes may be targeted in established scar to improve appearance and pliability of the tissue.Applicability of Research to PracticeThis work increases our understanding of the changes underlying scar maintenance and may facilitate new interventions to improve patient outcomes and reduce the burden of fibrosis.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.413
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 436 The Epidemiology and Prognosis of Patients with Massive Burns: A
           Multicenter Study of 2,483 Cases
    • Authors: Shen C.
      Abstract: IntroductionEpidemiological study of massively burned patients in our country remains unclear. This study was designed to investigate the epidemiological characteristics and evaluate the burn index (BI) and other risk factors associated with the prognosis of massively burned patients.MethodsThe data of 2,483 patients with ≥30% total body surface area burned admitted in 2014 were retrieved from 106 burn centers in our country. Information on epidemiological features and the outcome were collected for retrospective analysis.ResultsApproximately 17.76% of patients were admitted to the local burn center after 6 hours post-burn injury. The mortality was 9.79%, and the area under the receiver operating characteristic curve for BI was .941. When the value of BI was above a threshold of 29 in the 0-14 yr age group, 43.5 in the 15-59 yr age group and 35.5 in the 60 yr or older age group, the mortality increased significantly. Multivariate logistic regression analyses showed that the odds ratio of death increased 6% with an increase in the BI of 1.0. Patients older than 60 yr, the admission time longer than 6 hours post-injury and patients with a combined inhalation injury were at a higher risk of death.ConclusionsThe etiological characteristics of the different age groups should be considered for prevention. BI can be regarded as a reliable index of prognosis in severely burned patients. The results showed that a large BI, elderly age, delayed admission post-injury and combined inhalation injury are the main risk factors for extensively burned patients.Applicability of Research to PracticeEpidemiological studies are valuable in preventing burn injuries. The awareness of epidemiological characteristics of burn patients can help the people to prevent burn injuries and assist doctors to providert better burn care.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.332
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 477 A New Era of Reconstruction Options Following Necrotising Fasciitis: A
           Case Series Using a Synthetic Dermal Substitute
    • Authors: Damkat-Thomas L; Greenwood J, Salna I, et al.
      Abstract: IntroductionNecrotising fasciitis (NF) is a rare, life threatening, soft-tissue infection characterised by rapidly spreading inflammation and necrosis of the skin, subcutaneous fat, and fascia. Despite the uncommon nature of this condition, over the last decade, there has been a five-fold increase in the incidence of NF. Following suitable debridement and wound control, these cases are frequently managed on burns units as they require complex reconstructions. When skin grafts are used, their contraction can result in contracture of joints, or the neck. On the other hand, reconstruction using tissue flaps can be bulky, with poor contour definition and healing of both acute reconstructions, and their donor sites, can be challenging in the physiologically unstable patient.MethodsAll cases in which synthetic dermal substitute has been employed in necrotising fasciitis wound reconstruction have been included. Medical records and operation notes were reviewed retrospectively, including clinical photographs. Photographs were taken of all wounds at each surgery and dressing change. The data collected included demographics, length of stay in hospital, description of defect following serial debridement, indication for synthetic dermal substitute, time from implantation to split skin grafting and complications.ResultsThe cohort includes anterior neck defects exposing major vessels (2/7), multiple exposed ribs on the chest wall (2/7), lower limbs crossing knee or ankle joints (3/7) and a lower limb amputation by hip disarticulation (1/7). The mean age was 58 years (31 to 88 years), and the male to female ratio = 3:4. The median inpatient bed days from first debridement to discharge following split skin graft take was 62 days. No Synthetic dermal substitute was lost and no graft was lost over integrated synthetic dermal substitute.ConclusionsOur data supports previous published evidence that temporising with a dermal substitute is a viable reconstructive option in necrotising fasciitis defects. This is the first published series of the use of a completely synthetic dermal substitute in necrotising fasciitis wounds as an effective alternative.Applicability of Research to PracticeSynthetic dermal substitute offers a dermal substitute option for use in necrotising fasciitis, our results indicate that synthetic dermal substitute integration and split thickness graft take is high despite the challenging nature of the wounds and patient co-morbidity.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.371
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 236 Nutrition Support through Sedative Procedures: A Retrospective
           Comparison of Feeding Methods in Pediatric Burn Patients
    • Authors: Boland L; Goldberg A, Hall J, et al.
      Abstract: IntroductionThe hypermetabolic response to thermal trauma increases nutritional risk in pediatric burn patients. Interruption of feedings due to necessary clinical procedures leads to calorie and protein deficits, a constant challenge for the clinician. New methods for providing nutrition support that are safe and effective are needed. The objective of this study was to evaluate the nutritional and clinical outcomes associated with post pyloric enteral nutrition (EN) provided throughout sedation in pediatric burn patients as compared to a current standard of care of using parenteral nutrition (PN).MethodsA retrospective medical record review, grouping patients based on the type of nutrition support (EN or PN) received throughout sedative procedures was conducted. Sedative procedures included bedside dressing changes and operating room visits. Nutritional outcomes examined included: percent calorie goal achieved, percent protein goal achieved, and nil per os (NPO) hours. NPO hours refers to withholding any form of EN. Clinical outcomes included: intensive care unit (ICU) length of stay (LOS); total LOS; days on mechanical ventilation; days to wound closure; central venous catheter (CVC) days; hyperglycemic events; EN intolerance; and line infection. Statistical analysis was performed using repeated measures of ANOVA.ResultsPatients receiving PN had on average 13 more NPO hours than the EN group (p=.000), and a mean difference of 1 more hyperglycemic event (p=.03). There was an average of 1.6 more tube feeding intolerance events in the EN group, when compared to the PN group (p=0.01). There was no statistical significance between the EN and PN group in percent calories and protein goals achieved, wound closure days, LOS, ICU LOS, CVC days, or days on mechanical ventilation.ConclusionsContinued enteral nutrition support through sedation allowed patients to meet their goal calorie and protein requirements without adverse clinical outcomes. Parenteral nutrition can also be used safely in order to minimize nutritional deficits due to NPO time when unable to feed intraoperatively.Applicability of Research to PracticeThis work describes an effective feeding method that can be used to avoid nutritional deficits in patients during sedative procedures.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.163
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 388 Novel Anti-infectives Against Intestinal Barrier Derangement Following
           Burn - Site Infection
    • Authors: Almpani M; Adiliaghdam F, Hodin R, et al.
      Abstract: IntroductionBurn-site infections (BI), commonly due to Pseudomonas aeruginosa, have been associated with deranged intestinal integrity, allowing bacteria and their products to translocate from the gut to the circulation, leading to severe sepsis. The P. aeruginosa quorum sensing (QS) system MvfR controls the expression of many virulence molecules, and several toxic products. The role of QS in intestinal integrity alterations has not been previously interrogated. Utilizing the anti-MvfR QS-inhibitors we have discovered, we assessed the contribution of QS in the intestinal barrier dysfunction following BI.MethodsFollowing induction of a 30% dorsal burn in C57BL/6 mice, a clinical P. aeruginosa isolate (PA14) was intradermally inoculated at the burn wound. MvfR inhibitor was administered at 2, 4, 8 and 16 hours following BI. Mice were gavaged with Fluorescein Isothiocyanate-Dextran (FITC-Dextran). Permeability was assessed by serum FITC concentration, bacterial translocation to the mesenteric lymph nodes (MLNs), and tight junction alterations in the ileum. Intestinal inflammation was determined by ileum TNF-α and fecal lipocalin-2. Serum endotoxin levels, and PA14 systemic dissemination were also assessed.ResultsMvfR function exacerbates the post-burn intestinal hyperpermeability in thermally injured and infected mice. Inhibition of MvfR function with our anti-QS anti-MvfR agents, significantly decreases FITC flux out of the gut, diminishes bacterial translocation from the intestine to the MLNs, and improves tight junction integrity. Moreover, inhibitor administration alleviates the intestinal inflammation, by reducing the ileal TNF-α and fecal lipocalin-2 levels. Besides, it is associated with lower systemic endotoxin levels and decreased PA14 dissemination from the burn wound to the ileum.ConclusionsCollectively, our results show that inhibition of this QS system mitigates gut hyperpermeability by attenuating the derangement of morphological and immune aspects of the intestinal barrier, indicating that MvfR function is crucial in the intestinal integrity deterioration following P. aeruginosa burn-site infection.Applicability of Research to PracticeAn anti-virulence approach targeting MvfR, could offer a new therapeutic approach against multi-drug resistant P. aeruginosa infections following thermal injuries. Since this approach is targeting virulence pathways that are non-essential for growth or viability, it would not to impose a strong selective pressure on bacteria, thus preventing resistance emergence, while it would preserve the beneficial enteric microbes. Importantly, improving the intestinal integrity that is deranged as a result of BI, our strategy could effectively prevent the gut-derived sepsis syndrome following burns.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.289
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 74 Adipose Tissue from Burn Patients is Proinflammatory, Lipolytic and a
           Key Initiator of Hepatic Dysfunction
    • Authors: Auger C; Pang B, Shao L, et al.
      Abstract: IntroductionSevere burns induce systemic dysfunction characterized by chronic increased resting energy expenditure, catabolism of fat and muscle tissues, hepatomegaly and liver damage. The role of adipose tissue in initiating these complications has not been adequately defined. The aims of this study were to characterize the adipose tissue secretome of burn patients and delineate the extent of damage these biomolecules exert on hepatocytes compared to healthy control adipose.MethodsWhite adipose tissue (WAT) from burn patients admitted to a local burn centre requiring surgery and healthy controls undergoing elective procedures were used to prepare explant cultures. Gas chromatography-mass spectrometry and cytokine arrays were applied to characterize samples. These were subsequently incubated with human hepatocytes (HepG2) to elucidate their effects on cellular function. Seahorse XF96 analysis was used to study mitochondrial dynamics, and expression of endoplasmic reticulum (ER) stress and apoptosis markers were probed.ResultsHere, we show that WAT from burn patients undergoes extensive lipolysis and the release of inflammatory mediators compared to healthy control tissue. Treatment of hepatocytes with burned adipose explant media significantly raised ER stress and apoptosis markers while increasing mitochondrial oxygen uptake and inducing UCP2-mediated uncoupling (p ≤ 0.05). Further, the adipose secretome of burn patients alters nutrient homeostasis and mitophagy in hepatocytes, as indicated by the phosphorylation of acetyl-CoA carboxylase (Ser 79) and changes to mTORC1 and PINK1 expression.ConclusionsThe adipose tissue, generally regarded as a mere storage depot, is often overlooked as a contributor to systemic dysfunction post-trauma. Our results single out the adipose secretome of burn patients as an inducer of hepatocellular ER stress, mitochondrial hyperfusion/uncoupling and ultimately, cell death.Applicability of Research to PracticeThe data herein indicate that the adipose tissue acts as an initiator of systemic alterations following burn. Therapeutic interventions which reverse these morphological changes to WAT may be beneficial in reducing systemic complications.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.076
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 34 Direct Comparison of Different Porcine Thermal Injury Models - Is it
           Apples to Apples'
    • Authors: Gibson A; Moffett L, Andrews C, et al.
      Abstract: IntroductionA vast array of animal models are used in burn injury research, however the porcine model is the most homologous to human skin. The abundance of differing models in the literature and the lack of details regarding exact procedures makes comparison of research between investigators challenging and ultimately impacts translation to humans. We aimed to compare three well-established porcine thermal injury models from distinct research programs to highlight this often unrecognized barrier to progress in the field of burn injury.MethodsInvestigators were identified based on recent and robust publications containing porcine burn injury models. Investigators were asked to submit paraffin embedded tissue samples from deep partial thickness thermal injuries obtained on the day of injury. Protocol details including animal characteristics, thermal injury methods, and timing of sample collection were collected directly from individual investigators to allow for precise methodologic comparison across groups. All tissue sections were stained at one institution using Hematoxylin and Eosin (H&E) or Gomori Trichrome. The sections were reviewed in a blinded fashion by three independent labs using a standardized scoring sheet for H&E sections that used cellular and collagen changes to define injury.ResultsDuroc and Yorkshire pig breed models were compared. Temperatures ranged from 80–200 degrees Celcius, and contact time from 15–20 seconds. All groups used unique in-house manufactured metal thermal injury devices with pressure and temperature control. H&E scoring revealed two of the three models produced injury limited to the upper third of the skin, while one model produced injury into the lower third of the skin. Trichrome stain revealed collagen denaturation in only one of the three models.ConclusionsThe depth of injury varied across the three highly accepted models despite each individual lab defining the injury as a deep partial thickness burn. Future studies are necessary to identify the model that most accurately reproduces injury in human skin to facilitate translation of thermal injury modeling in humans.Applicability of Research to PracticeA standardized model yielding a defined burn depth is critical for advancement of translational burn research that adds to the body of knowledge required to diagnose injury and develop novel therapeutics.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.038
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 336 Outcomes Following Use of Negative-Pressure Wound Therapy Over
           Autologous Meshed and Non-Meshed Skin Grafts
    • Authors: Patel A; Bell D.
      Abstract: IntroductionNegative pressure wound therapy (NPWT) over complex wounds can control exudate, decrease infections, and improve revascularization. Previous studies have already shown NPWT is safe, efficacious, and cost-effective in the burn surgery population. However, no study specifically addresses differences in outcomes between meshed and non-meshed skin grafts dressed with NPWT. Our study aims to characterize patient outcomes with respect to two groups: meshed and non-meshed autologous skin grafts.MethodsPatients undergoing autologous skin grafting with or without a NPWT dressing for any burn injury over a nine-month period were included. Xenografts and Allografts were excluded. Through retrospective chart review, the following were assessed: burn etiology, use of NPWT, graft take and size, meshed or non-meshed, seroma incidence, and length of hospital.ResultsOur study included 122 patients (who underwent 324 split thickness skin grafts) and consisted of 57% males, 57% Caucasian, and an average age of 41. Burn injury etiologies consisted of scald (55%), chemical (25%), flame (15%), and contact (5%). Average 2nd degree TBSA in our cohort was 2.34%, 3rd degree TBSA 4.50%, and total TBSA 5.35%. 100% patients received a split-thickness skin graft (STSG), with an average graft size of 120.5 cm2. There was 100% graft take and 0% seroma formation in all patients. Of STSGs, 38% received a NPWT dressing. Those with the dressing had an average LOS of 14.8 days, whereas those without the NPWT dressing had an average LOS of 13.8 days. Of those with a STSG, 66.7% were non-meshed and these patients had an average LOS of 11.7 days versus 33.3% meshed with an average LOS of 13.8 days. There were no significant differences in LOS when stratified by TBSA and graft size.ConclusionsThere exist many options for dressings after repair of burn injuries, each with its own unique advantages. Using a NPWT over a STSG, and using a meshed graft resulted in a slightly longer LOS than their respective counterparts in our study. There were, however, no differences in graft take in using a NPWT dressing.Applicability of Research to PracticeSome surgeons may be hesitant in using a NPWT dressing over a non-meshed graft because it may be more difficult to extract any residual fluid, but our data shows that there is no increased seroma rate by this method.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.247
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 288 Potential Organism Transfer in a Pediatric Burn Unit, Pre- and
           Post-UV-C Implementation
    • Authors: Weitz J; Durkee P, Dwyer A, et al.
      Abstract: IntroductionA clean environment is critical to prevent hospital-acquired infections (HAIs) through organism transfer. A previous study at our hospital indicated that UV-C effectively eliminated pathogens and commonly seen organisms from patient rooms. Subsequently, our facility purchased a UV-C device and incorporated it into our terminal cleaning practices. The patient room may play a role in the transfer of multi-drug resistant organism (MDRO), if the previous occupant was colonized or infected with an MDRO. We hypothesized that the incorporation of UV-C technology into our terminal cleaning practices would decrease the number of organisms potentially acquired by patients during hospitalization.MethodsAfter IRB approval, four high-volume rooms were selected for data collection. Electronic medical record reports generated a chronological list of patients that occupied each of the designated rooms. Microbiology organism reports were generated for each patient during his or her hospital stay. The reports were further delineated to identify which organisms were present on admission and those that were acquired during the hospital stay. The data were de-identified and collated in spreadsheets retaining only the organism list and the chronological order. Each room’s data was compared independently. Organisms acquired during a patient’s hospital stay that had also been recovered from the previous patient were considered a potential transfer from the environment. Reports were generated for 2015, 2017 and 2018. Total number of pathogens was compared by the Wilcoxon rank sum test, and specific pathogens were compared by Fisher’s exact test.ResultsStatistically significant decreases in total number of pathogens were found between 2015 and 2017 (p<0.0001) and between 2015 and the combination of 2017 and 2018 (p<0.0001). There was no significant pathogen difference between 2017 and 2018. Significant differences for specific pathogens between 2015 and 2017 and those between 2015 and the combination of 2017 and 2018 are shown in Table 1. None of the specific pathogens showed any differences between 2017 and 2018.ConclusionsImplementation of UV-C technology as an integrated part of terminal cleaning processes significantly reduces the number of potential transferred organisms. Fewer pathogens present reduces risk for acquiring HAIs.Applicability of Research to PracticeReducing environmental contamination through effective touch - free technology reduces risk for acquiring HAIs.Table 1Organism2015 vs. 2017 p-value2015 vs. 20172018 p-valueC. albicans0.00680.0119P. aeruginosa<0.0001<0.0001E. coli0.03540.0466E. faecalis------0.0319MRSA0.01160.0118
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.205
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 118 Sarcopenia is Associated with Worse Postoperative Outcomes in Burn
           Patients
    • Authors: Murray B; Liu Y, Baldea A, et al.
      Abstract: IntroductionLoss of lean muscle mass has been associated with worse outcomes in cancer patients. Although there have been studies that have examined outcomes related to metabolic derangements in burn patients, the prevalence of sarcopenia and sarcopenic obesity and their effects on operative outcomes of burned patients have yet to be described.MethodsSkeletal muscle mass index was measured for patients with ≥20% surface area burn admitted to the ICU with computed tomography scan performed between January 2007 and January 2017. Skeletal muscle area was measured at the L3 level and calculated the skeletal muscle mass index (cm2/m2). Sarcopenia was defined as two standard deviations below the index level defined in healthy adults. Statistical analysis evaluating demographics, co-morbidities and outcomes in relation to sarcopenia was performed.ResultsNineteen patients were included in the study with a mean age of 43.2 (21–67) and 68.4% were male. The mean % burn surface area was 43.9% (20–77.5). Mean number of burn operations per patient was 8.6 (1–27). 47.4% of skin grafts healed after the first attempt and overall healing was 73.7%. Mean length of stay (LOS) was 99.4 days (median 91, 16–257). Mean BMI was 29.3 (21.2–41.8). The prevalence of sarcopenia was 68.4%; 69.2% of males and 66.7% of females. Sarcopenia was associated with overall postoperative complications (p=0.007) and superficial wound infections (p=0.012) and pneumonia (p=0.013). There were 6 (31.5%) patients categorized as having sarcopenic obesity. These patients were more likely to use or have used alcohol (p=0.004, 0.009) and had increased number of overall and burn-specific operations (p=0.006 and 0.011, respectively). They were more likely to have PE (p=0.028). Sarcopenia was not significantly associated with gender, race, co-morbidities, LOS, readmissions or mortality.ConclusionsOur findings suggest that decreased lean muscle mass at time of burn injury is associated with worse postoperative outcomes, especially if the patient is both sarcopenic and obese. Interestingly, co-morbidities and age were not associated with sarcopenia. In these patients, nutritional support was maintained throughout hospitalization. However, it may require interventions targeting muscle strengthening, even during these lengthy hospitalizations to help improve operative outcomes in severely burned patients.Applicability of Research to PracticeThis study accomplishes two goals: it highlights the significance of close monitoring of nutritional status on eventual outcomes in Burn Patients. Also, we are describing another method of investigating metabolic studies, not previously applied to Burn Patients, that will allow centers to better care for their patients.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.119
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 435 Streets of Fire - Revisited
    • Authors: Kowal-Vern A; Ruiz K, Richey K, et al.
      Abstract: IntroductionPavement/street/highway contact burns are rare. This study compared recent contact burns to a 1995 report of this injury. It was hypothesized that there was a significant increase in the number of pavement/street burns, as a result of increased current ambient air temperatures. An additional hypothesis was that motor vehicle crash burns were significantly < severe than burns from hot pavements/streets.MethodsThis was a two-year retrospective burn center study, June-September (2016-2017). Parameters studied were: age, %TBSA (total body surface), injury location, injury, mortality, LOS (length of stay), ICU (intensive care unit) and Vent (Ventilator) days, OR (Operating Room) visits, and procedures.ResultsIn 1995, 95-100 o F ambient air temperatures were sufficient to produce the 111o F critical burn pavement and street surface temperatures. During this study, the average daily ambient air temperatures averaged 95-88o F. The highest daily temperature measurement during the noon hour ranged from 108-119 o F. Compared to contact burns from motor vehicles crashes (MVC), road rash or other methods, patients with contact pavement/street burns were: older (p<.0002); had slightly smaller % TBSA; similar length of stay; fewer OR visits, procedures, (ICU) and Vent (Ventilator) days. There were no fatalities in the motor vehicle crash/road rash groups but a 5.4% (8) mortality in the pavement/street burn group.ConclusionsAlthough there has been a 7.5 fold increase in pavement/street contact burns, the ambient temperatures had not increased significantly since 1995. Except for the significantly older age and increased mortality, the pavement/street burn group was similar to the motor vehicle group. Morbidity associated with age may have contributed to their injures being more severe.Applicability of Research to PracticeResearch on patient characteristics will facilitate development of prevention measures for the population.Demographic Characteristics of Pavement/Street Contact Burns (2016-2017)Parameters (range)Pavement/AsphaltMotor VehicleRoad RashOtherNumber173291710Age (Years) *p<.0002*55 (1-94)*31 (6-75)30 (4-69)35 (7-78)%TBSA4 (1-27)6 (1-19)10 (2-20)4 (1-15)LOS/%TBSA2 (0.1-20)3 (0.2-12)1 (0.2-6)2 (0.3-26)LOS11 (1-109)12 (1-48)11 (1-28)11 (1-26)ICU (days)4 (1-69)15 (1-44)1 (1-14)-Ventilator (Days)6 (1-58)15 (1-36)8 (1-14)-OR (#)1 (0-14)3 (0-13)2 (0-4)1 (0-2)Procedures (#)5 (0-106)11 (0-68)10 (0-24)0.5 (0.5-15)Mortality (%)8 (5.4%)000
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.331
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 522 Influence of Secondary Dressings on the Effect of a Bacterial Derived
           Cellulose Dressing: Results of an Animal Study
    • Authors: Tuca A; Funk M, Palackic A, et al.
      Abstract: IntroductionA balanced moist wound environment and wound surface increase the effect of various growth factors, cytokines and chemokines, and cell growth. This can stimulate cell growth and wound healing. Considering this fact, we tested the effects of different secondary wound dressings and their evaporation of water when used with bacterial derived cellulose dressing in vitro and in vivo in a porcine donor site model. The aim of this study was to evaluate how the different rates of evaporation affect wound healing.MethodsBacterial derived cellulose dressing is a hydroactive wound dressing made from pure biotechnologically derived cellulose with more than 95% sterilized water in a sodium chloride solution. To further determine evaporation behavior, bacterial derived cellulose dressing was tested in vitro, either alone or in combination with secondary wound dressings. As secondary dressings we chose materials which are used in clincal routine such as cotton gauze, Jelonet, Aqacel Extra and Opsite Flexifix. Furthermore, in a porcine donor site model, we analyzed the effect of bacterial derived cellulose dressing, with and without secondary dressings, on wound healing in vivo. For this, the dressing materials were placed on 3x3 cm sized dermotome wounds of 1.2 mm depth arranged in groups of six on the flank of a domestic pig. The healing progress was analyzed macroscopically and histologically after 5 days.ResultsThe in vitro experiments showed rapid water evaporation rates from bacterial derived cellulose dressing when using cotton gauze or Aquacel Extra as a secondary dressing, an intermediate evaporation rate after coverage with Jelonet, and a much slower rate when using Opsite Flexifix as secondary dressing. The histological results from the animal study showed that bacterial derived cellulose dressing in combination with cotton gauze or Aquacel Extra had comparable high rates of re-epithelialization. Whereas these were reduced when using Jelonet as a secondary dressing. The secondary dressing with Opsite Flexifix resulted in very slow water evaporation from the wound with consecutive very bad to non-healing wounds and a high maceration rate.ConclusionsIn the present study we were able to show that the moisture of the wound environment and evaporation from the wound can be specifically influenced by using bacterial derived cellulose dressing in combination with cotton gauze, Jelonet, Aqacel Extra and Opsite Flexifix.Applicability of Research to PracticeThe results of this study make it possible, depending on the type of wound, to positively influence cell growth and thus accelerate wound healing. This can be of great benefit in clinical wound management, especially in burn injuries and chronic wounds.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.412
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 235 No Association of Oxandrolone Administration and the Development or
           Severity of Heterotopic Ossification Following Burn Injury
    • Authors: Thorpe C; Ulcer Ozgurel S, Simko L, et al.
      Abstract: IntroductionOxandrolone, a synthetic analog of testosterone, has been an important innovation to burn injury’s standard of care over the past twenty years. Heterotopic Ossification (HO) is a severe complication of burn injury; and it has been previously demonstrated that male mice form more trauma-induced HO volume compared to female mice. Additional literature suggests a congruent cellular phenomenon: osteoblast differentiation activated via androgen receptor binding. This work examines if there is an association between oxandrolone administration during the acute burn hospitalization and HO development by exploring historical clinical data bridging the introduction of oxandrolone into clinical practice. In addition, we examine associations between oxandrolone administration and HO in a standardized mouse model of burn-related HO.MethodsData for the review were obtained from a single academic burn center. Adult burn patients who were admitted to their acute stay between the years 2000 and 2014, survived through discharge, and had an HO risk factor of 7 or higher out of 13, were selected for analysis. HO risk scores were calculated for consecutive admissions based on burn size and the presence of deep burns to specific sites including head and neck, trunk and upper extremities as previously reported. Oxandrolone administration, clinical and demographic data, and the diagnosis of HO were recorded. Human data were analyzed with logistic regression. Associations of oxandrolone with HO were examined in a mouse HO model. Specifically, mice were administered oxandrolone or vehicle control following burn/tenotomy to examine any potential effect of oxandrolone on HO. Mouse data were analyzed by Student’s t-test.ResultsThere was no significant association between oxandrolone administration and HO development. In agreement with the retrospective review, in the mouse model, the oxandrolone group did not have a statistically significant increase in HO. (p=0.18 for total HO in 800 Hounsfield Units (HU)).ConclusionsNo association between oxandrolone administration and the development or severity of HO following burn injury was found.Applicability of Research to PracticeOxandrolone is not associated with HO development in burn patients.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.162
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 476 Reconstruction of Complex Lower Extremity Wounds with a Hyaluronic
           Acid Based Skin Substitute and Split Thickness Skin Grafting: A Case
           Series
    • Authors: Velamuri S.
      Abstract: IntroductionLower extremity complex wounds with exposed bone are particularly challenging to reconstruct, especially in the presence of chronic diseases such as diabetes mellitus, congestive heart failure and renal failure. We used a bilayered skin substitute consisting of a biodegradable hyaluronic acid based matrix. The matrix acts as a scaffold for cellular colonization and has a semipermeable silicone membrane that controls water vapor loss. In this case series, we present the results of three patients with complex lower extremity wounds characterized by exposed bone and tendon.MethodsThis case series is a retrospective, review of three patients with chronic diseases who underwent reconstruction of lower extremity wounds with a hyaluronic acid based skin substitute. Patient demographics, comorbidities, procedure details and the post-operative course including complications were collected from the electronic medical record.ResultsThree patients were included in the case series with an age of 44,49 and 50 years respectively. All had a past medical history significant for diabetes mellitus, hypertension and peripheral vascular disease. Two had end stage renal disease requiring dialysis. The wound etiology included a third degree foot burn, diabetic ulcer, and trans-metatarsal amputation with osteomyelitis. All three were complicated with exposed bone and two had exposed tendon. Time between application of the skin substitute and skin grafting was 25,26 and 28 days respectively. Time to complete healing was 31,42 and 57 days. Complications included partial skin graft loss in one patient.ConclusionsMany complex lower extremity wounds with bone/tendon exposure require flap based reconstruction. In selected cases, application of a hyaluronic acid based skin substitute followed by split thickness skin grafting may be considered as a viable alternative in limb salvage. This could help prevent the patient being subjected to additional lengthy complex surgical procedures.Applicability of Research to PracticeSkin substitute containing hyaluronic acid may be considered another option in reconstrcution of complex lower extremity wounds.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.370
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 387 Hyperspectral Imaging in Burn Evaluation from Bench to Bedside: A Case
           Report
    • Authors: Gu G; McCarthy M, Lujan-Hernandez J, et al.
      Abstract: IntroductionPredicting burn depth has been the goal of imaging technologies over the last thirty years. Hyperspectral imaging (HSI) is a FDA approved non-invasive method of evaluating oxygenation and perfusion of soft tissue using light wavelengths within the visible spectrum. We have demonstrated in a mouse model that HSI can correlate and potentially predict burn depth earlier than clinical assessment with accuracy. We now describe the potential clinical utility of HSI in evaluating burn depth in a patient.MethodsA patient sustained thermal burns of various depths to his body. He was evaluated in the ED 6hr post-injury. Based on initial clinical exam, burns were identified as of second (2Deg) and third degree (3Deg). 2Deg were subdivided into superficial (2DegS) and deep (2DegD). HSI images were taken on arrival and on post-burn days 3, 4, and 5 in parallel with clinical evaluation by the authors. HSI readings from unburned skin from day of burn were used as control. As a function of tissue perfusion, arbitrary units for oxygenated (OxyHb) and deoxygenated hemoglobin (DeoxyHb), as well as total hemoglobin (THb) were obtained with HSI. Some areas were found to have deepened from post-burn day 1 to 5, and underwent excision and grafting. Clinical impression from PBD0 and PBD5 (intra-operative) were used for correlating HSI findings.ResultsFindings at 6 hours post-burn compared to control resulted as above: OxyHb: +124% (2DegS), +28% (2DegD) and -42% (3Deg). DeoxyHb: +8% (2DegS), -38% (2DegD), -64% (3Deg). THb: +60% (2DegS), -8% (2DegD) and -56% (3Deg). Comparison within 2nd degree group yielded +134% OxyHb, +97% DeoxyHb and +120% THb in 2DegS compared to 2DegD at 40hr post burn. Findings correlated with our animal model, which showed similar trends for all markers.ConclusionsOur data suggests a correlation between HSI results and burn depth, consistent with our animal model. Increased Thb and OxyHb as markers of hyperperfusion in 2DegS could be explained by reactive erythema, which is then blunted in 2DegD due to deeper dermal plexus damage, and ultimately destroyed in 3Deg, resulting in negative values. HSI can detect trends in oxy and deoxygenated hemoglobin as markers of tissue perfusion, consistent with burn deepening. This data can be useful in determining the depth of 2nd degree burns as that delineation is vital to surgical decision making. If further validated in humans, this could represent a potential application of HSI to predict burn depth, potentially improving patient outcomes.Applicability of Research to Practice:
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.288
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 33 Automated Burn Assessment using Deep Learning and Computer Vision
    • Authors: Pridgen B; Jopling J, Sheckter C, et al.
      Abstract: IntroductionAccurate diagnosis of burn size and depth guides decision-making for resuscitation and triage to burn centers. Inaccuracies in initial burn assessment by non-specialists in emergency departments may lead to inappropriate initial treatment. An automated burn assessment tool may address this problem without involving burn specialists. Deep learning and computer vision present an opportunity to provide automated size and depth assessments using digital images of burns.MethodsDigital images of 793 acute burns were collected from Google images and a regional burn center. Edges of burn images were manually segmented. The resulting 1570 individual burns were labeled for depth by three independent reviewers. The 1501 burns with majority agreement were used for training, validation, and testing of a deep learning algorithm. This algorithm performed a semantic segmentation task of whole images in which each pixel within an image was assigned a depth. This algorithm was developed for several binary classification tasks, including evaluating for superficial partial thickness or deeper burns. The performance of the algorithm was assessed using standard metrics including intersection over union (IOU), pixel accuracy (PA), receiver operating characteristic curve area under the curve (ROC-AUC), and precision-recall curve average precision (PR-AP).ResultsIn 96% of the burns, a majority of independent reviewers agreed on the depth of the burn. The interrater reliability between the labelers yielded an overall Fleiss kappa of 0.60. When performing a binary class evaluation for superficial partial thickness or deeper burns, the algorithm had excellent performance across each of the commonly reported metrics including IOU 0.82, PA 0.94, ROC-AUC 0.98, and PR-AP 0.91. The included figure represents average performance of the algorithm. There were expected improvements or declines in performance with simpler or more difficult classification tasks, respectively.ConclusionsThis study represents the largest known dataset of annotated burn images. A computer vision algorithm using deep learning achieved accurate performance on automated semantic segmentation of burns.Applicability of Research to PracticeThis computer vision algorithm allows for automated identification of clinically meaningful burns of superficial partial thickness or deeper. Deploying this tool to first line providers, who could easily access this tool with a smartphone, may allow for more accurate initial management of patients with burns.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.037
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 73 Establishment of New Cellular Model Supportive of Burn-Induced
           Perturbation in Mitophagy Response
    • Authors: Yasuda N; Shakuo T, Kashiwagi A, et al.
      Abstract: IntroductionAutophagy is considered an indispensable mechanism for cellular adaptation to various stresses. Mitophagy, or autophagic degradation of mitochondria sequesters damaged mitochondria and functions as the essential quality control (QC) system of this organelle. When mitophagy is disturbed, damaged mitochondria are not cleared and will produce superoxide. Our previous mouse study documented a compromised mitophagy response in burn injury (BI), suggestive of poor QC of mitochondria in severe BI. The detailed mechanisms have not been investigated, due to the lack of feasible cell culture model to investigate this phenomenon.MethodsWe have established a C2C12 myocyte cell line stably expressing markers for auto/mitophagy, by transfecting (1) GFP-LC3 for monitoring auto/mitophagosomes, (2) mCherry-tubulin for studying the formation of microtubule (MT), and/or (3) tandem-fluorescent LC3 (tfLC3) to document the maturation/prematuration status. The cells were also stained by LysoTracker Blue and MitoTracker DeepRed for monitoring lysosomes and mitochondria, respectively. By incubating the cells with day 3 BI or sham-burn serum harvested from rats (30%, systemic BI), cells were primed with simulated BI-stress or the control treatment. Twelve hours later, mitophagy was invoked by incubating the cells with CCCP, and the response of mitophagy was monitored by time-lapse observation under confocal microscopy. The obtained findings were confirmed by Western Blotting.ResultsIn control C2C12 cells, MTs were formed upon induction of mitophagy, and the mitophagosomes and lysosomes travelled along the MT. In the BI-serum treated group, however, the cells showed disturbed formation of MT, and the vesicle trafficking of mitophagosomes and lysosomes was markedly perturbed. Accordingly, the maturation of mitophagy was perturbed in BI group. Western Blotting experiment showed reduced flux of mitophagy in BI group, confirming the microscopy data.ConclusionsWe have established a feasible cell culture experimental model to study mitophagy responses in skeletal muscles to study the effect of BI. MT formation and mitophagosome trafficking were both perturbed in BI group, suggesting that MT disturbance can be one of the important molecular event affected by BI, and involved in the poor adaptation of organs in BI subjects.Applicability of Research to PracticeWe have identified MT network disturbance as the potential molecular target for future therapeutic intervention aimed at ameliorating disturbed auto/mitophagy response. Our newly established cell culture model will be a feasible tool to study the detailed mechanism of BI-induced muscle dysfunction, and to test the drug efficacy.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.075
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 117 Serum Level of Musclin Is Elevated Following Severe Burn
    • Authors: Song J; Clark A, Huebinger R, et al.
      Abstract: IntroductionMuscle wasting induced by severe burn worsens clinical outcomes and is associated with hyperglycemia. A novel muscle-specific secretory factor, musclin, was reported to regulate glucose metabolism with a homologous sequence of natriuretic peptides. The purpose of this study was to investigate musclin expression in response to burn injury in both human and animal models.MethodsSerum was collected from 13 adult burn patients and circulating levels of musclin protein were measured via elisa. The cytokine profile was measured by multiple immunoassay. Following the clinical study, we used a burn rat model with 40% TBSA to study the time course of musclin expression till day 14 after injury. Rat serum and muscle tissue sample were harvested. Finally an in vitro study was applied to investigate whether the muscle cell C2C12 myoblast expressed musclin under 10% burn serum stimulation.ResultsPearson analysis showed that there was a significant positive correlation of musclin expression to total body surface area of burn in patients (p = 0.038). Musclin expression was significantly positively correlated to IL-4, IL-7, IL-12, and IL-13 in burn patients’ serum (p < 0.05). In the animal study, we found that level of musclin was elevated at 6 hour and day 1 in burn rat serum (p<0.05). In vitro, musclin mRNA expression in C2C12 muscle cells was significantly increased with burn serum stimulation at 24 hours (p<0.05).ConclusionsSerum level of musclin was elevated both in human patients and in a rodent burn model; musclin levels were correlated to the severity of burn injury as well as to an elevated cytokine profile in patients; in vitro stimulation with burn serum increased musclin expression.Applicability of Research to PracticeThe current study implies a novel biomarker candidate in response to the progress of burn severity.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.118
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 286 Comparative Cost Effective Analysis for the Use of Allograft in Second
           Degree Burns
    • Authors: Van Vliet M.
      Abstract: IntroductionThe use of allograft is the burn wound has been clinically shown to decrease days to epithelialization, mitigate pain associated with wound management and limit burn wound infection. While there is no general consensus for the management of a second degree burn, most surgeons will manage either with topical antibiotic creams, topical silver or allograft placement. The purpose of this paper is to complete a cost-effective analysis for the use of allograft in second degree burns as a means of justifying the increased cost.MethodsWe completed a comparative cost effective analysis for the use of allograft in second degree burns. The model compares this technology to topical antibiotic therapy and topical silver dressings. The model was “rolled-back” in order to obtain quality adjusted life years. Incremental cost-effectiveness ratios were used to summarize the cost effectiveness of this intervention.ResultsWhile the use of allograft in second degree buns comes with a greater cost than other modalities, it is associated with an improvement in quality adjusted life years. This increased cost is justified by an acceptable willingness to pay threshold.ConclusionsAllograft in the use of second degree burns is a clinically effective means to treat a second degree burn. This technology comes with an improvement in QALYs and the cost is justified by a comparative cost effectiveness and an acceptable societal willingness to pay threshold.Applicability of Research to Practice: This is applicable to everyday use.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.204
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 335 Contact Burns:A Retrospective Analysis of Etiology and Demographics
    • Authors: Miyasako S; Curtis E, Mandell S, et al.
      Abstract: IntroductionContact burns are a common type of burn injury seen frequently in the inpatient setting. They are responsible for up to 9% of all burns in the American Burn Association National Burn Repository, making them the third leading etiology for hospital burn admissions. This study aims to explore risk factors and possible prevention strategies for patients with contact burns admitted to a regional burn center.MethodsFollowing IRB approval, burn registry data was reviewed for all individuals admitted with a contact burn from January 2008 through December 2017. Data collection included sex, age, etiology of contact burn injury, burn size as % TBSA (total body surface area), and length of inpatient hospital stay (LOS).Results192 patients met study criteria for etiology consistent with a contact burn with 68% male and 32% female. Data were categorized by age (see table).ConclusionsIn this single-center cohort, contact burns affected 2.7% of all admissions during a 10-year review period. The most common age range was 1-9 years (47%). Injury caused by contact with a cooking surface/cookware was the leading etiology for all age groups except those over 60 years. Most contact burns were less than 1% TBSA burn size and required less than 4 days of inpatient hospitalization.Applicability of Research to PracticeUnderstanding the etiology of injury relative to age is a key step in prevention outreach education.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.246
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 434 A 54-Year Retrospective Review of Deaths at a Pediatric Burn Unit
    • Authors: Poster J; Chu C, Weber J, et al.
      Abstract: IntroductionBurn care and prevention over the last 54-years has drastically improved. We examine the descriptive statistics of burn deaths at our pediatric burn unit.MethodsWe retrospectively reviewed patient deaths at our pediatric burn unit from 1964 to 2018. Descriptive statistics were analyzed across each of the six decades. Mortality rates were calculated from 1994 to 2018 because admissions data was available starting from 1994.ResultsA total of 141 patients died at our pediatric burn unit since 1964. In Table 1, the number of deaths decreases in each subsequent decade. Mean TBSA and mean 3rd degree burn stayed relatively consistent across each decade. The modified Baux score trended upward, which evidences it’s increased accuracy for current burn methods. In Figure 1, fire/flame burns were the most common cause of death in each decade. Total fire/flame deaths was 124. In Figure 2, the frequency of death per year trends downward. In Figure 3, mortality rate per year trends downward.ConclusionsOur results show the impact of improved burn care methods and burn prevention to minimize burn deaths over the last 54 years. This is evidenced by the steady decrease in the number of deaths in each decade. Burn prevention programs can further minimize burn-related deaths by focusing on prevention of fire/flame related burns.Applicability of Research to PracticeBurn care teams should extend their expertise beyond acute wound closure to include reconstruction and rehabilitation methods.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.330
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 234 A Multi-center Survey of Vitamin D Monitoring and Supplementation in
           Patients with Thermal Injuries
    • Authors: Zavala S; Hill D.
      Abstract: IntroductionThe pleotropic effects of vitamin D supplementation in deficient patients have been demonstrated. There are few studies of vitamin D in burn patients. The optimal dose, formulation, and route of administration for vitamin D supplementation is unknown, as is the frequency or necessity of monitoring vitamin D concentrations in burn patients. The primary objective of this study is to describe the current practice of monitoring and supplementing vitamin D in burn patients admitted to a burn center.MethodsThis was a survey conducted of subscribers to the American Burn Association Pharmacy Special Interest Group email listserv in May 2018. Recipients were asked whether their center monitored vitamin D concentrations and if supplementation was routine. Data collected included: whether vitamin D concentrations were obtained on admission, preferred replacement regimen, and timing of subsequent concentration obtainment.ResultsA total of 21 responses were received. Eight respondents (38.1%) routinely check 25-hydroxyvitamin D concentrations. Two centers check concentrations on admission, two centers check within 48 hours of admission, three centers check within one week of admission. One center specifically monitors concentrations only for patients with a > 20% total body surface area (TBSA) burned. Five centers report rechecking concentrations within weeks to months of the initial level,. Four centers primarily use ergocalciferol, three use cholecalciferol, and one has no preference. Dosing varied greatly between sites. Two respondents reported adjusting dose based on degree of deficiency and admission concentration. One respondent reported a dosing regimen adjusted to age and percent TBSA burned. Thirteen respondents (61.9%) do not routinely check vitamin D concentrations, but may if patients are healing poorly, malnourished, or per nutritionist or nephrologist recommendations. One of the burn centers, who does not routinely monitor concentrations, supplements all burn patients who have ≥ 15% TBSA with cholecalciferol 2000 units daily. Barriers to routinely monitoring vitamin D concentrations cited were cost, inability to analyze in-house, and lack of evidential recommendations for monitoring and supplementing patients with thermal injuries.ConclusionsThe current practice of monitoring and supplementing vitamin D varies widely across burn centers. Future studies using consistent monitoring and dosing should be conducted to determine the clinical benefit of adequate vitamin D levels in burn patients.Applicability of Research to PracticeSuggest performing a multi-center clinical trial and developing recommendations for routine monitoring and supplementation of vitamin D in burn patients.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.161
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 521 Adipose Derived Stem Cells Populated Matrix Promotes Wound Healing in
           Mice
    • Authors: Forbes D; Pakyari M, Kilani R, et al.
      Abstract: IntroductionWound repair and regeneration is a multidisciplinary field of research with considerable value to the treatment of deep and large burn injuries. These injuries lack an appropriate tissue scaffold and pro-healing cells making them difficult to heal. An alternative to the often limited autologous skin is a therapy that would restore the essential matrix and cellular components for rapid healing. Over the last decade, mesenchymal stem cells have become the focus of research in regenerative medicine owing to their ability to provide the essential building blocks for skin regeneration. Herein, we utilize a validated method of wound splinting in a delayed-healing murine model to investigate the pro-healing effects of adipose-derived stem cells (ASCs) in a novel dermal matrix in the healing of complex wounds.MethodsTo ensure ASC survival within the gel matrix, cells were incubated with the matrix for 14 days prior to in-vivo studies. Viability was tested at days 3,7 and 14. With ethics approval, full-thickness 8 mm diameter excisional wounds were created and splinted on the dorsum of genetically diabetic mice. Eighteen animals were randomized into 3 groups: 1) occlusive dressing only (control), 2) gel, 3) gel + ASCs. Wounds were photographed at days 0, 7, 10, 14 and wound area was calculated using Image J Software. Histologic samples were examined for architecture and collagen content. Capillary formation was quantified using immunofluorescence. GFP labelling of ASCs was used to track the fate of these cells within the wound.ResultsThe gel matrix supported the survival of ASCs. In-vivo testing showed that treatment groups had accelerated epithelialization. Wounds treated with gel + ASCs had a significant reduction in wound size after Day 10 (p<0.001). Histology showed earlier re-epithelialization in both treatment groups. GFP staining showed co-localization of ASCs with capillaries. There was an increased number of capillaries in the wound site for groups treated with ASCs compared to control (p <0.001).ConclusionsASCs are a viable source of pro-healing cells in deep wounds. The cell populated matrix accelerated wound healing, decreased wound size and increased capillary formation in a delayed-healing murine model.Applicability of Research to PracticeThe dermal gel matrix combined with ASCs is a feasible treatment strategy for complex or large burn wounds. The dermal gel matrix component has since been shown to be non-toxic to human cells. The protocol can be modified for human use by using autologous ASCs.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.411
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 386 Monocyte Dysfunction Following Pediatric Thermal Injury May Predict
           the Development of Nosocomial Infections
    • Authors: Thakkar R; Devine R, Fabia R, et al.
      Abstract: IntroductionCritical injury- and illness-induced immune suppression has been associated with adverse outcomes in both adults and children. This acquired form of immunosuppression is poorly understood in pediatric burn patients, who have infectious complication rates as high as 60%. The cellular elements of the immune system are critical after burn injury because of the lack of skin barrier function. Our primary objectives are to determine if thermal injury results in monocyte dysfunction and if this form of acquired immunosuppression is associated with increased risk for nosocomial infections (NI). Our hypothesis was that pediatric burn patients with NI after thermal injury would have lower numbers of monocytes as well as decreased monocyte function compared to those that did not have NI.MethodsWe performed a prospective, longitudinal immune observation study at a single ABA-verified pediatric burn center. Whole blood samples from burn patients were used to assess monocyte function via the measurement ex vivo LPS-stimulated TNFα production capacity along with CD14+ monocyte cell counts and monocyte HLA-DR expression by flow cytometry. These values were obtained within the first week of thermal injury. Nosocomial infections were defined using CDC criteria. Immune parameters were compared between patients who went on to develop NI and those that did not.ResultsWe enrolled a total of 26 patients, ages 6 months to 15 years, and 10 went on to develop a NI. Within the first three days of burn injury, children who developed infection had lower whole blood ex vivo LPS-induced TNFα production capacity (420 pg/mL vs. 1200 pg/mL, p =0.0002), CD14+ monocyte counts (371 cells/µL vs. 675 cells/µL, p =0.025), and CD14+ monocyte HLA-DR expression (58% vs. 87%, p =0.02) compared to those that did not develop infection.ConclusionsThese findings indicate that monocyte dysfunction may occur following pediatric thermal injury and appears to be a risk factor for the development of nosocomial infections. This may represent a therapeutic target and is the subject of ongoing prospective study.Applicability of Research to PracticeAbsolute monocyte numbers are readily available to clinicians with some centers having access to monocyte functional measurements. These studies may be useful diagnostic tools to identify thresholds of immune function as well as targets for therapeutic intervention in pediatric burn patients.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.287
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 72 Eradicating CLABSI in the Burn Center Through Nursing Education
           Interventions
    • Authors: Strait E; Cabrera J, Garner J, et al.
      Abstract: IntroductionCentral line acquired bloodstream infections are dangerous for patients and costly for hospitals. Burn patients with central lines can be difficult to manage due to prolonged necessity of a central line, placement of lines in close proximity to a burn wound and inability to apply an occlusive dressing. An infected burn wound can lead to a blood stream infection. The infection may incorrectly be attributed to a central line if documentation of the burn wound is inadequate. Nursing maintenance of central lines and proper documentation of possible infection sources can significantly impact infection rates. Nurses need to know the correct maintenance and documentation practices to provide the best care for patients with a central line.MethodsA scenario based pre-test was developed to test RN knowledge of proper maintenance techniques for central lines. A written pre-test was also administered asking questions pulled directly from our institution’s Central Venous Access Guideline of Care. Feedback was provided immediately after completion to RNs. Hands on proctored central line dressing changes done at annual skills day. Further education offered on central line maintenance, indications and discontinuance. Post test was then administered after all RNs had received education. Wound Care Assessment and documentation module was developed for annual skills day and taught to 100% of nurses in the Burn Center. Updates were made to the Burn Wound Care note to include infectious terminology according to CDC guidelines. Implemented daily nursing rounds on central line necessity and maintenance practices.ResultsNurses performed poorly on the scenario and written test addressing central line maintenance. Post test scores improved after receiving education. Central line Standardized Infection Ratio and Standardized Utilization Ration both reduced to below expected level. CLABSI rates decreased by 77% (from 13 to 3) from 2016 to 2017. No CLABSIs reported since July of 2017.ConclusionsDemonstrates that nursing focused education initiatives, along with continued follow up, can help reduce CLABSI occurrence in the Burn Unit.Applicability of Research to PracticeCritical Care units can reduce CLABSI by educating nurses.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.074
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 475 Acute and Reconstructive Burn Surgery with a Bilaminate Polyurethane
           Skin Substitute: A Case Series
    • Authors: Sangji N; Levin J, Friedstat J, et al.
      Abstract: IntroductionDermal replacement devices are useful in coverage of large burn patients with limited donor sites, burns with exposed tendons, and reconstructive procedures. Commonly used dermal substitutes are costly and vulnerable to infection. A polyurethane bilaminate device which is relatively microbial-resistant has recently become available. Here we review our initial experience using this device.MethodsIn late 2017 we began using BTM in reconstruction and recently extended use to acute burns. We identified representative patients (5 reconstructive and 1 acute) who were grafted with BTM, followed in 3 weeks by split thickness skin grafting (STSG) or in one case cultured epithelial autografting (CEA) and 6:1 meshed STSG. Charts were reviewed for wound bed infection defined as purulent destruction of bilaminate +/- surrounding erythema in adjacent skin, requiring debridement or the initiation of antibiotics.ResultsThere were no wound infections in the patients and BTM was well incorporated and easily delaminated within 3 weeks in every case. Subsequent autograft take was excellent. All surgeons in our practice reported ease of use in the operating room. Figure 1 shows the stages in axillary reconstruction of Patient 1, who underwent release and graft of his right axilla with BTM followed by STSG. Autograft take was 100% and ROM normalized. Figure 2 shows the results of a in Patient 2, who had a 95% TBSA burn and underwent excision and BTM placement followed by CEA. Her wound bed incorporated the BTM as well as in the reconstructive patients creating a robust surface for application of STSG and CEA.ConclusionsEase of use and engraftment of this bilaminate polyurethane device is as good or better than other analogous devices. We intend to use it increasingly in coming years for in both acute and reconstructive surgery.Applicability of Research to PracticeWe recommend the use of BTM as a wound bed matrix for acute and reconstructive burn patients.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.369
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 32 A Burn Team Notification Protocol Improves Emergency Department to Burn
           Center Admission Times
    • Authors: Staubli L; Wiktor A, Wagner A.
      Abstract: IntroductionMultidisciplinary Emergency Department (ED) protocols that alert specialty response teams have shown to reduce door-to-evaluation and treatment times, and have been associated with improved length of stay (LOS) and mortality. Such protocols are common for Trauma, Stroke and Myocardial Infarction but have not been well established for burns and frostbite. Initial management and resuscitation of these patients affects treatment options and long-term outcomes. Therefore, streamlined notification of the burn team is critical to mobilize appropriate resources and optimize patient outcomes. The purpose of this quality improvement (QI) project was to implement a standardized Burn Team Notification Protocol (BTNP) to expedite triage and transfer from the ED to the Burn Center.MethodsA multidisciplinary team of burn, trauma and ED representatives developed a three tiered triage notification system based on mechanism and extent of injury: activation, alert and consult. The highest level of notification, an activation, requires Attending-to-Attending discussion within 10 minutes of notification while the lowest level of notification, a consult, requires any burn provider response to the ED. Time from ED arrival to Burn Center admission for all patients was analyzed for 18 months prior and 18 months post-BTNP implementation. Under- and over-triage rates were also analyzed. Wilcoxon rank sum test was used to determine statistical significance of median ED times.ResultsDuring this QI project, 256 patients were admitted to our Burn Center from our ED; 120 presented prior to implementation of the BTNP and 136 presented after. Median time for ED arrival to Burn Center arrival for all patients reduced from 143 minutes pre-implementation (range 30–1134) to 112 minutes post-implementation (range 27–595) (p=0.001). Median time for ED arrival to Burn Center arrival for patients who met Burn Activation criteria reduced from 111 minutes pre-implementation (N=24, range 36–415) to 62 minutes post-implementation (N=29, range 27–163) (p=0.001). The median time reduction for patients who met Burn Alert criteria was not significant. After BTNP implementation, seven percent of all patients were under-triaged (N=10), and 33% of patients were over-triaged (N=45), either from the field or in the ED.ConclusionsA standardized multidisciplinary burn team notification protocol significantly improves ED arrival to Burn Center admission times, especially for the most critically injured burn patients.Applicability of Research to PracticeEstablishment of a tiered burn team notification protocol expedites ED to burn admission times. Future studies are needed to assess the impact of expedited admission on morbidity and mortality.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.036
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 116 Redefining Refeeding Syndrome in Burn Patients
    • Authors: Boyd A; Gervasio J, Blair M, et al.
      Abstract: IntroductionRefeeding syndrome is defined by metabolic changes, including fluid shifts and fluctuations in glucose, protein, and electrolytes, when initiating nutrition therapy. Refeeding hypophosphatemia, however, describes phosphorus depletion upon nutrition initiation. The objective of this study is to classify electrolyte deficiencies in burn patients as either refeeding syndrome or refeeding hypophosphatemia and to define risk factors for each.MethodsThis retrospective review included adult burn patients admitted from 10/1/16 to 8/31/17 with at least a 7 day length of stay. The primary outcome was to assess electrolyte deficiencies including hypophosphatemia (≤ 2.5 mg/dL), hypokalemia (≤ 3.5 mg/dL), and hypomagnesemia (≤ 1.6 mg/dL). Refeeding syndrome was defined as deficiencies in potassium, magnesium, and phosphorus at any point after nutrition initiation. Refeeding hypophosphatemia was defined as hypophosphatemia at any point. Baseline demographics were compared between groups to assess risk factors for each type of disorder.ResultsData were collected in 80 patients, of which 61% had refeeding hypophosphatemia, 16% had refeeding syndrome, and 23% had neither (p < 0.001). Median nadir potassium and magnesium levels were within normal ranges. Nadir phosphorus was markedly low [1.8 mg/dL (1.4–2.8)]. By Day 7, all levels had returned to normal. Additional results are listed in Table 1.ConclusionsResults of this subgroup analysis indicate patients with a major burn (≥ 20% TBSA) may be at a higher risk of developing refeeding syndrome. In addition, patients with inhalation injury are at a higher risk of developing refeeding hypophosphatemia.Applicability of Research to PracticeTo our knowledge, this is the first study of its kind to describe the incidence of refeeding hypophosphatemia and to evaluate risk factors for its development versus refeeding syndrome in burn patients. Future directions include further defining electrolyte deficiencies in burn patients with the goal of developing a unit-specific protocol for replacement that can be shared with other burn centers.Table 1.Electrolyte Deficiency Risk FactorsDemographicRefeeding Hypophosphatemia (n = 49)Refeeding Syndrome (n = 13)Neither (n = 18)p-valueTBSA (%), median (IQR)12 (5,20)18 (10,24)7 (2,11)0.020Inhalation Injury, n (%)13 (16)3 (4)1 (1)0.001Time to initiation of nutrition (hours), median (IQR)17 (6,37)14 (5,24)22 (16,24)0.284NRS-2002, median (IQR)1 (0,3)0 (0,3)1 (0,2)0.809Prealbumin (mg/dL), mean (SD)18 (8)17 (5)18 (7)0.993CRP (mg/dL), median (IQR)9.1 (2.3, 18.5)9.4 (0.1, 15.4)15.2 (3, 18.2)0.730
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.117
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 285 In Hot Water: Cooking Related Burn Injuries in the ED
    • Authors: Burton T; Savetamal A.
      Abstract: IntroductionMany of the burn injuries evaluated in emergency departments are directly related to cooking. A large majority of these injuries do not require admission to a burn center. Certain foods (or the preparation thereof) may be associated with more severe burns. This review of recent annual data from ED visits seeks to identify and stratify these foods and beverages by causative agent and severity of injury.MethodsInstitutional review board approval was obtained and retrospective review of ED visits in which burn was listed as admitting problem was performed from 10/2017 to 9/2018 accruing 390 patient visits. Data collected included age, gender, type of food that caused the injury, % TBSA, and whether they were admitted or discharged. Exclusion criteria included contact injuries from hot stove-top, work-related injuries, chemical, and electrical injuries.ResultsOf the 390 patients reviewed, 283 were excluded from this study (non-cooking related injuries), this resulted in a population of 107 patients. The mean age was 32 years old, 38 were male (35.51%) and 69 female (64.49%). Overall averaged TBSA % burn was 2.22%. Of the 107 patients in this cohort 14 were admitted to the burn unit (13.08%) and 93 patients were discharged (87.85%). Nineteen patients had burns associated with coffee (17.67%), 18 burned from soup (16.82%), 14 from tea (13.08%), 8 from water (7.48%) with the remainder due to various others. TBSA was averaged by the offending substance and found to 3.33% for soup, 2.6% for water, 2.38% for coffee, and 1.95% for tea. Of these injuries 71 (65.74%) were scald injuries from water based foods, 23 (21.3%) from foods cooked in/with oil, with the remaining 13 (12.04%) due to contact/other burn injuries. The majority of burn patients (71.43%) admitted had injuries due to water-based burns with 14.29% of each oil and other burns requiring admission.ConclusionsCoffee, tea, and soup all seemed to be the most prevalent causative agents accounting for the vast majority of burns seen by our ED in the last calendar year. All of these are water based scald injuries, which also account for the majority of burn admissions in this population. Interestingly, this is discordant with burn injuries seen in our inpatient setting in which the majority of injuries seem to be due to oil-based injuries likely from the higher stored thermal energy in such substances.Applicability of Research to PracticeEpidemiological review of a commonly seen cohort of patients encountered in burn and non-burn centers across the nation.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.203
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 334 Injury Pattern from Electronic Cigarettes (e-Cigs): A Multicenter
           Experience
    • Authors: Culnan D; Mullins F, Mir H, et al.
      Abstract: IntroductionElectronic cigarettes (e-Cigs) are an increasingly common etiology of burn injury. These injuries occur from battery explosions with flame, overpressure blast injuries, and chemical injuries. We present our multicenter 17-month experience with these injuries.MethodsAll burns evaluated in our burn centers from September 1, 2016 to January 31, 2018 were retrospectively analyzed. Patients with burns having an etiology of e-Cig injury were included and demographic data, injury pattern, treatment, and outcome were tabulated.ResultsOf 8,051 acute burn admissions, 65 patients were diagnosed with e-Cig burns. The average age was 32 years (SD 11, Range 14-62), with 60 males and 5 females. The average TBSA was 3.64% (SD 1.96%, Range 0.25-10%). These were deep burns with 68% having mixed-depth burns, 34% having no superficial burn, and 65% having some full thickness with an average full thickness of 2.68% TBSA. Burn locations were as follows: 28% hand, 3% upper extremity, 12% face and/or neck, 9% genitals, 68% thigh, and 14% leg. Three patients had blast injuries of dislodged teeth, hearing loss, and a pneumothorax. Fifty patients needed operations with 48 treated initially with skin substitute and 2 having primary autografts. Of the skin substitute patients, 20 subsequently required secondary autografting. In the operative group wound areas were 1860 cm2 +/- 71.9 SEM (n=37). Mean length of stay was 1.79 days with SEM 0.2 (n=19), though 30 were treated solely as outpatients. Total outpatient treatment was 4.83 weeks with SEM 0.53 (n=24). Total time to definitive closure was 5.2 weeks with SEM 0.56 (n=16). 20 patients completed treatment and were healed; 9 were lost to follow up. 15 patients were treated nonoperatively with local wound care, debridement, and topical antimicrobials. Of these, the average TBSA was 1.46% with a range of 1-5.5% and average superficial area of 2.2%, deep partial of 1.5%, and full thickness of 2%.Conclusionse-Cig burns are increasingly common as burn mechanisms, and we present the largest series to date with patients suffering both flame and blast injuries with an incidence of 0.8%. Notably, this injury tends toward deep burns with 77% of patients requiring operations and 34% requiring autografting.Applicability of Research to PracticeGiven the frequent need for operative intervention and 4.6% association with significant blast injury, these injuries should be referred to a burn center.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.245
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 232 Volume Based Enteral Feeding in Burn Patients
    • Authors: Regojo P; Clarke S.
      Abstract: IntroductionNutrition for the burn patient is crucial for injury recovery. Enteral nutrition (EN) in burn care is used to accommodate the need for increase calories and protein, decrease weight loss, reduce mortality, and maintain gut barrier function, mucosal integrity and blood flow. Enteral feeding is interrupted due to wound care, surgery, hemodynamic instability, gastric residuals and sepsis. In a review of our burn patients’ EN, it was estimated that patients received an average of 70% of their prescribed EN goal. Once the tube feed is held, it is difficult to anticipate that the prescribed daily amount of required EN will be met. The purpose of this project was to determine if a different method of feeding should be examined. A literature search provided limited information regarding burn patients receiving adequate EN that was not rate based. Volume based EN was reported in ICU trauma patients, with little complications. Would the use of a volume based tube feed (VBTF) guideline deliver the necessary volume, calories, & protein better than rate base EN in burn patients'MethodsA Quality Improvement project was initiated in our burn center to increase the amount of EN the patient received. Patients who required EN for greater than 1 day were prescribed volume base feeding until the EN was no longer required. The Registered Dietitian determined the goal rate, per hour & goal volume per 24 hrs. of enteral feed. EN ran at goal until feedings were held. Nursing would note the number of hours EN was off. Volume base feed resumed when tube feed was turned back on at the rate according to the VBTF chart posted at the bedside. The new rate of feeding continued until 7am the next day at which time the rate was reset to its original prescribed rate.ResultsForty-four patients were followed for two years. Patients included in the VBTF program received feedings 1–99 days. All patients who were administered VBTF received greater than 80% of their prescribed formula. Through this collaborative program and change of practice, the burn team was able to provide the needed nutrition and calories required with no GI complications.ConclusionsEnteral nutrition is essential for burn recovery when the patient is unable to receive enough oral nutrition for injury recovery. VBTF has shown to be a successful method of providing the nutrition and calories required when tube feedings are held for a limited amount of time.Applicability of Research to PracticeAdditional methods for feeding burn patients via the enteral route need to be available. Further investigation of the effectiveness of VBTF guidelines on wound healing and injury recovery should be investigated.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.160
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 432 Feasibility and Implementation of the YP Face IT Online Program for
           Youth Recovering from Burn Injuries
    • Authors: Riobueno-Naylor A; Williamson H, Kogosov A, et al.
      Abstract: IntroductionRecent research has shown that many children and adolescents recovering from burn injuries experience anxiety over their scars and/or other appearance-related differences. The current study assessed the feasibility of recruiting participants for a clinical trial of an online program called YP Face IT (YPF) that was designed to help young people with visible differences such as burn scars to cope with social and psychological stresses. The study’s first phase assessed the feasibility of having subjects complete the baseline measures of appearance concern and anxiety. The second, ongoing, clinical intervention phase added an assessment of patients’ willingness to participate in the YPF trial.Methods12-17-year-old English-speaking patients and their parents were recruited in the outpatient clinic of a pediatric burn hospital. Recruitment included pre-screening scheduled patients through the hospital’s electronic medical record and then obtaining clinician approval to approach eligible patients. In both phases of the study, participants completed a 90-question (~20 minute) battery made up of 5 brief anxiety measures and a 3-question debriefing questionnaire (DBQ). The DBQs asked participants if they had appearance concerns (AC) and if they would be interested in learning about/participating in YPF and/or other supportive resources. All participants were invited to use YPF, even if they did not endorse AC.ResultsDuring the first phase of the study, 174 outpatients met study criteria and 39 (22.4%) of them agreed to participate in the study. Thirteen (33%) patients and/or their parents indicated on the DBQ that the child had AC and 16 (41%) were interested in participating in YPF or other appearance-related resources. During the initial two months of the second phase of the study, 62 patients were eligible, 17 (27.4%) agreed to participate in the study, 6 (35.3%) endorsed AC, and 7 patients (41.1%) elected to participate in the YPF clinical trial. Interested patients had a full range of burn scarring (TBSA range 1-87% in both phases).ConclusionsThe current study confirmed previous reports of the existence of appearance concerns in a substantial proportion of young people being seen in an outpatient burn clinic. New findings suggested the feasibility of offering the YP Face IT program in this setting, with more than one third of study participants expressing interest in participating in a clinical trial of this program.Applicability of Research to PracticeThe current study provides evidence of appearance related anxiety within populations of adolescents recovering from burn injuries. Many of these adolescents are interested in clinical resources that could help. Clinicians who treat adolescents with burn injuries could bring existing resources to their attention.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.329
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 520 Micro/Nanobubbles: A Novel Modality for Burn Oxygenation and Healing
    • Authors: Sayadi L; Rowland R, Naides A, et al.
      Abstract: IntroductionOxygen is one of the most important elements in all stages of wound healing. It is involved in killing bacteria during the inflammatory phase, increasing keratinocyte differentiation and reepithelization during the proliferative phase, and supporting myofibroblast differentiation and collagen cross-linking during the maturation phase. Current therapies which deliver oxygen to wounds such Hyperbaric Oxygen Therapy (HBOT) and Topical Oxygen Therapy (TOT) are costly, not portable, and their efficacy is limited to certain wounds. A new innovation, micro/nanobubbles (MNBs), are miniature gaseous voids that allow for oxygenation of wounds. Given their high oxygen carrying capacity, MNBs offer an inexpensive technology for oxygenating burns and can be supplemented a part of hydrotherapy. The aim of this current study was to use MNBs to deliver oxygen to burn wounds and determine their healing potential.MethodsFor this study, full thickness burns were placed on the dorsum of six Sprague Dawley rats. Three of these rats received a constant topical treatment of saline infused with MNBs for two weeks after burn placement. The remaining three rats received the control treatment of saline without MNBs. Spatial Frequency Domain Imaging (SFDI) was used during and after the treatment course to measure the tissue scattering and oxygenation within the burn wound and surrounding region, and to quantify the progression of burn healing out to 28 days after burn wound placement.ResultsThe reduced scattering coefficient, an SFDI measured parameter related to light interaction with tissue structure, decreased within the first week after the burn region in both the experimental and control sets. After 9 days of treatment, the value of the scattering parameter within regions treated with MNBs increased more rapidly towards baseline (unburned) scattering values when compared to saline treated controls. Additionally, measurements of tissue oxygen saturation increased in the areas treated with MNBs, but not in the areas treated with the saline control.ConclusionsMNB-treated full thickness burn wounds show improved healing compared to those treated with the saline control. SFDI measurements demonstrate that MNB application increases tissue oxygenation. Measurements of structural changes indicate MNB-treated burns begin to proliferate and remodel at earlier time-points than burns receiving the saline control.Applicability of Research to PracticeApplication of micro/nanobubbles to burn wounds and surrounding tissue increases tissue oxygenation, supports and accelerates burn wound healing.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.410
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 381 Budget Impact of Autologous Cell Harvesting Device (ACHD) Use versus
           Standard of Care (SOC) for Treatment of Severe Burns: A Case Study
    • Authors: Foster K; Kruger E, Kowal S, et al.
      Abstract: IntroductionA new FDA-approved ACHD for the treatment of acute thermal burn injuries achieves comparable healing outcomes to SOC treatment, using significantly less donor skin, without compromise to patient safety. ACHD can be used as a primary intervention for deep partial-thickness burns (DPT) or as an adjunct to widely meshed split-thickness skin grafts (STSG) for mixed-depth (including full-thickness [FT]) burns without continuous dermis. Use of ACHD in clinical practice should be informed by both clinical evidence and likely economic impact to a burn center. This analysis projects the budget impact of ACHD via consideration of key burn center costs, SOC surgical practices and patient mix.MethodsA hospital-perspective model depicts the acute burn care pathway (wound assessment, debridement/excision, temporary coverage, permanent closure and rehabilitation). This published, validated US Burn Care Model leverages regression models from the ABA’s National Burn Repository to project number of excision, debridement and grafting procedures and length of stay (LOS) based on unique patient characteristics. Information on US SOC practice patterns and hospital costs were derived from 12 burn surgeons and 3 US burn centers. Use of ACHD was assumed to impact permanent closure and inpatient rehabilitation for DPT and FT/mixed burns of TBSA 10%+, with clinical impact based on trial publications. Model assumptions and inputs were validated or updated to reflect costs and practice patterns for the burn center.ResultsUse of ACHD enables an autograft sparing technology to be leveraged in clinical practice, translating into multiple benefits, including reductions in donor site and an estimated 66% reduction in grafting surgeries. These benefits support notable reductions in LOS (from 7723 to 6517 inpatient days), inpatient rehabilitation fees as well as OR time, materials and support staff costs. Considering patient mix and unique burn center costs for an estimated 400 patients with TBSA≥10% annually, ACHD use is cost saving with a projected 16% (~$14M) reduction in total costs from $87M to $73M annually.ConclusionsWhen considering costs and practice patterns the, use of ACHD alone and in combination with STSG is likely to reduce burn center costs and LOS.Applicability of Research to PracticeThe growing body of clinical publications on ACHD use provides evidence supporting its clinical effectiveness. This work considers the financial impact of ACHD to manage serious burns, finding that benefits are projected to translate into reductions in LOS and overall savings to a burn center.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.286
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 71 Standardized Suicide Screening in Adult Burn Patients to Determine Risk
    • Authors: Taveras L; Imran J, Cunningham H, et al.
      Abstract: IntroductionPre-morbid psychiatric disorders are common among burn survivors and psychiatric symptoms often persist or worsen post-injury, leading to increased suicide risk. The prevalence of suicide risk is unknown and providers caring for burn survivors do not routinely screen for suicide risk and may miss the opportunity for early intervention to prevent injury or death. The characteristics of at-risk burn patients have yet to be elucidated. Using a brief, standardized tool to identify at-risk patients may be an important first step in reducing risk. The aims of this study are to report the prevalence of suicide risk in burn patients and identify demographic and burn-related characteristics of these patients.MethodsThe Columbia-Suicide Severity Rating Scale, screener version, recent (C-SSRS) was administered by nursing staff to burn patients 18 and older upon admission, or as soon as clinically feasible. Adult burn patients with screening data between February 2015 and February 2018 were included. Patients were classified as at risk if any item was positively endorsed on the C-SSRS and no risk if all responses were negative. Significance was set at α = 0.05. Statistical analysis was performed using Student t test and χ2 test where appropriate.ResultsOut of 1,474 burn patients evaluated during the study period, 1,444 (97.96%) were screened for suicide risk. Suicide risk was identified in 64 (4.43%) patients. At-risk patients did not have a partner (n = 52, 81.25%), had higher TBSA (16.25% vs 9.23% and had a longer LOS (24.4 days vs 8.6). Overall, female patients had higher proportion of at risk status (8.21% vs 3.23%, p < 0.05). There were no differences in age, race/ethnicity, payor status and mortality.ConclusionsOur universal suicide screening process identifies an at risk subpopulation of burn patients. Higher injury burden and poor social support system are associated with suicide risk.Applicability of Research to PracticeOur findings suggest that a portion of patients admitted for burn injuries endorse suicide risk factors. This risk may go undetected without standardized screening. These findings suggest at risk patients may be identified by standardized screening tools and referred for appropriate management and follow-up.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.073
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 31 Implementation of Provincial Adult Burn Clinical Practice Guidelines
           and their Impact on Patient Outcomes
    • Authors: Mankowski P; Genoway K, Gregory T, et al.
      Abstract: IntroductionIn 2011, our institution implemented province clinical practice guidelines were implemented in 2011 to standardize acute burn management and resuscitation practices to optimize consistency in patient care prior to transport to a designated burn center. A retrospective review was performed to evaluate the impact of these guidelines on burn patient care since their implementation.MethodsA review of patients admitted at our burn center between 2011–2016 after the implementation of the 2011 provincial burn guidelines was performed evaluating TBSA estimation, resuscitation records and clinical outcomes. Study inclusion required patients greater than 18 years old with a TBSA burn injury larger than 15%. Patients were categorized into groups based on treatment adherence to the 2011 guidelines and if they were treated initially peripherally or directly at our quaternary burn center. Results were compared previous burn outcome data obtained prior to guideline implementation.ResultsA total of ninety-five patients met the study inclusion criteria. In the first 24 hours after acute burn injury, the patients that were initially managed peripherally and then transferred, received an average of 5.8cc/kg/%TBSA of fluids when there was no evidence of guideline adherence. If the guidelines were implemented only after transferred to our center, patients received an average of 5.0cc/kg/%TBSA. For burns patients where guidelines were utilized both peripherally and after transfer, an average 4.0cc/kg/%TBSA was used for resuscitation. Complications such as respiratory failure (17% vs. 11%), abdominal compartment syndrome (4% vs. 0%) and acute kidney injury (50% vs. 33%) more frequently developed when the guidelines were implemented only after transfer to our burn center.ConclusionsThe implementation of new clinical practice guidelines to aid in fluid resuscitation following major burns has decreased IV fluid administration for patients initially assessed in peripheral low volume centers. Early guideline implementation may decrease burn associated systemic morbidities.Applicability of Research to PracticeThis research reinforces the importance of standardizing treatment practices to improve burn patient care and discusses the obstacles associated with disseminating specialized clinical skills and knowledge.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.035
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 284 Resurgence of Electronic Cigarette Explosions Despite Regulation
    • Authors: Williams F; Nizamani R, Sljivic S, et al.
      Abstract: IntroductionElectronic cigarettes (e-cigarettes) were introduced in the United States over ten years ago. Despite their increasing popularity, the production of e-cigarettes was largely unregulated until 2016. There have been numerous poisonings, toxic ingestions, and injuries related to e-cigarette use. We reported a series of nine patients with serious burns sustained as a result of e-cigarette explosions up to that date. Delays in regulation have led to a resurgence of cases in our institution. We now report a series of 30 cases with serious burns.MethodsSingle-site, retrospective, non-randomized, observational cohort study. Patients were identified using an institutional Burn Center registry, and linked to clinical and administrative data. All patients admitted between December 1st, 2015 and September 30, 2018 were eligible for inclusion. Demographics, length of stay (LOS), cost, and mortality were evaluated.ResultsNine patients were admitted prior to electronic cigarettes becoming regulated by the Federal Drug Administration (FDA). Twenty-one such cases presented after the FDA delayed regulatory statutes.The average age was 32. Eighty-three percent of the patients were male. Eight patients required admission to our burn intensive care unit. Eighteen patients required excision and autografting. Five patients underwent debridement and xenografting. One patient required orbital enucleation for a ruptured globe. No patients died in the study period.ConclusionsWe speculate that poor regulation of e-cigarette production has led to manufacture of faulty devices prone to malfunctioning. The previous lack of regulation of e-cigarettes led to increases in adverse events, including device explosions. Now that the Food and Drug Administration (FDA) has regulatory authority over e-cigarette production, regulatory standards must include manufacturing oversight and design modifications to decrease morbidity from e-cigarette explosions and fires.Applicability of Research to PracticeThis represents an emerging public health problem.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.202
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 115 Burn-induced Microglia Activation is Associated Motor Neuron
           Degeneration and Muscle Wasting in Mice
    • Authors: Ma L; Khan M, Yasuhara S, et al.
      Abstract: IntroductionBurn injury (BI) leads to both systemic and neuro-inflammation that is associated with muscle wasting and weakness, which increase morbidity and mortality. Disuse atrophy is concomitantly present in BI patients. Most studies have focused only on muscle with little attention to role of central nervous system (CNS) in the neuromuscular changes. We tested the hypothesis that BI-induced muscle wasting is related to CNS microglia activation and cytokines and chemokine release that results in spinal cord ventral horn motor neuron degeneration.MethodsBody surface area (35%) BI, BI with immobilization or Sham BI was administered to mice. Spinal cord (L3-L4 segments) and skeletal muscle tissues were harvested on day 7 and 14 after perturbations to examine microglia, motor neuron and skeletal muscle changes.ResultsBI significantly (p < 0.05) activated microglia, evidenced by its increased density (proliferation) around motor neurons and inflammatory cytokines (IL-1β, TNF-α) and/or chemokines (CXCL2) expression at day 7 and 14, that was more prominent in BI with immobilization. Additionally, ventral horn motor neurons apoptosis and down-regulation were observed at both periods, again significantly magnified by concomitant BI with immobilization. The pretzel-shaped synapse was disintegrated and fragmented with BI, especially with immobilization together with significantly decreased gastrocnemius, tibialis and soleus muscle masses.ConclusionsBI induces microglia proliferation and activation (cytokine and chemokine release), degeneration of ventral horn motor neurons and skeletal muscle mass loss, those were accentuated by concomitant immobilization. The mechanisms connecting microglia activation and motor neuron degeneration to muscle mass loss require further delineation.Applicability of Research to PracticeOur research supports and partly explain the increasing burn related peripheral neuropathy clinical findings and open a new field of research the potential mechanisms in burn induced muscle wasting.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.116
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 333 The First Twenty: The Use of Synthetic Dermal Substitute in
           Significant Burns; Outcomes and Lessons Learned
    • Authors: Damkat-Thomas L; Kurmis R, Heath K, et al.
      Abstract: IntroductionIn 2014, following the development of a biodegradable temporizing matrix at our centre, we began to use it in the management of significant burn injuries. It is a totally synthetic bi-layer, dermal replacement scaffold, composed of a 2mm thick, biodegradable polyurethane foam and a non-biodegradable polyurethane film (seal). We aim to present our experiences from the first twenty significant burn cases using synthetic dermal substitute, along with the evolution of its use since adopting it into our clinical practice.MethodsPatients were identified via our departmental database. Medical records were retrospectively reviewed, with patient demographics and clinical outcomes being collected, including: • complications, • number of operative procedures, • time to grafting, • time to range of movement (ROM) and mobilisation, • scar management requirements, • time to commencement of scar management, • scar outcomes, • reconstructive surgical requirements.ResultsOf the 20 patients, 75% were male (n=15) with an age range of 17-94 years, representing total body surface area burn range of 5-75%. Mean time from admission to completion of synthetic dermal substitute application was 5 days (± SD=7) for upper limb sites and 10 days (± SD= 11) for lower limb sites. Mean time from admission to completion of grafting to synthetic dermal substitute sites was 46 days (± SD= 6). Graft loss over integrated synthetic dermal substitute was minimal. Complication rates including synthetic dermal substitute loss and graft loss will be presented. Reasons for loss include seroma/heamatoma, infection/contamination, early loss of seal due to shear, and failure to integrate due to fat necrosis beneath the dermal substitute. With experience in the use of synthetic dermal substitute, the number of operative procedures for dressing changes has decreased over time and functional and scar outcome measures are promising.ConclusionsChanges in surgical practices for the management of burn injury require the evaluation of their implication on multi-disciplinary team clinical practice in addition to patient outcomes, to ensure the ongoing delivery of high quality burn care. Our introduction of synthetic dermal substitue as a dermal substitute has improved clinical resource utilisation in addition to improving patient outcomes.Applicability of Research to PracticeSynthetic dermal substitute offers an alternative dermal substitute option for use in burn injury, our results indicate that it may decrease hospital resource utilisation and improve patient outcomes.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.244
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 474 Cyanoacrylate Glue for Sheet Graft Fixation in Patients with Burn
           Injuries
    • Authors: Pham C; Larson J, Collier Z, et al.
      Abstract: IntroductionSkin sheet graft edges are traditionally secured with staples or sutures which are associated with pain on removal and increased operative time, respectively. Little data exists documenting the outcomes of using cyanoacrylate glue (CAG) for fixation of the skin graft to the wound margin. Our burn center recently adopted the use of CAG for skin sheet graft fixation in adults and children. Here, we present the outcomes of sheet grafts fixed with CAG in patients sustaining burn injuries requiring skin grafting.MethodsA retrospective review was performed of all patients receiving CAG-fixated sheet grafts by a single surgeon over a 12-month period in 2017-2018. The primary outcome was percentage graft take as determined on first post-operative dressing take-down. The secondary outcomes were post-operative wound infections, re-operation rates, and CAG-related complications.ResultsWe identified 11 patients and 15 grafts that fit inclusion criteria. Most patients were young (16 ±15%), male (64%), and had small burns (mean, 10 ± 10% TBSA) as a result of flame injuries (36%). All patients (100%) demonstrated excellent graft take, with a mean percentage graft take of 96 ± 9%. The mean graft size was 226 ± 389 cm2. No patients developed post-operative wound infections or required re-operations. There were no CAG-related complications including allergic reactions, sheer with dressing takedown, or separation of grafts from the wound edges.ConclusionsWe find CAG to be an effective and efficient method of fixation for sheet grafts in burn patients. All patients had successful graft take, and there were no CAG-associated complications. In addition, we empirically noted a reduced operative time compared to using sutures for graft fixation and lower dressing change opioid requirements compared to patients who require staple removal. Prospective studies are required to better define graft survival with CAG fixation when compared to traditional methods, amount of operative time saved, and reductions in dressing change opioid requirements.Applicability of Research to PracticeCAG is a promising tool in a system that increasingly emphasizes cost-effectiveness, patient comfort, and satisfaction.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.368
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 231 Underweight Patients have an Increased Mortality Following Burn
           Injury: Clinical Outcomes Reported in the National Burn Repository
    • Authors: Nosanov L; McLawhorn M, Vigiola Cruz M, et al.
      Abstract: IntroductionBody mass index (BMI) has been established as a risk factor for increased morbidity and mortality in multiple clinical settings. While patients with elevated BMI often present with multiple associated comorbidities, low BMI predisposes patients to poor wound healing and injury recovery. The purpose of this study was to evaluate the association between BMI and clinical outcomes after thermal injury at a national level via the National Burn Repository (NBR).MethodsThe NBR (version 8.0) was queried for entries inclusive of codes for BMI. Data collected included patient demographics, BMI, injury mechanism and characteristics and clinical outcomes including hospital and intensive care unit length of stay, total ventilator days and mortality. Based on BMI, patients were categorized as underweight, normal weight, overweight, obese, super obese or morbidly obese. Chi-square and student t-tests were used for descriptive analysis, and logistic regression was performed to assess the impact of BMI on clinical outcomes.ResultsOf 172,640 patients in the NBR, BMI data were identified for 388, with 6.4% underweight, 15.7% normal weight, 14.2% overweight, 21.9% obese, 16.0% super obese, and 25.8% morbidly obese. Mean TBSA%, incidence of inhalation injury, length of mechanical ventilation, length of ICU stay, or length of hospital stay did not significantly differ by BMI. Only underweight status (BMI <19) was significantly associated with increased mortality (p < 0.001).ConclusionsAlthough a small minority of entries in the NBR have BMI documentation, this analysis importantly identifies low BMI, rather than obesity, as a significant risk factor for mortality following burn injury. Obese patient habitus may prove challenging from a nursing and surgical standpoint, but may not pose as significant of a risk as many might assume. Malnutrition, exacerbated by pre-injury underweight status, poses a serious challenge for wound closure. Careful monitoring and appropriate supplementation may mitigate associated risk. Given the implications of low BMI on clinical outcomes, additional emphasis should be placed on BMI documentation in the NBR.Applicability of Research to PracticePractices focused on early and aggressive nutritional supplementation for underweight patients may improve survivability following burn injury.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.159
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 431 Through the Eyes of Burn-Injured Youth - How Burn Camp Helps Survivors
           Thrive
    • Authors: Rimmer R; Bay C, Kalil E, et al.
      Abstract: IntroductionImprovement in acute burn care has increased the probability of survival of severely burned children who often experience disfigurement and physical/emotional pain. Recreational camps whose goal is to help them deal with their burn injuries have existed for several decades. This includes helping burned children cope with disfigurement and the psycho/social challenges of burn survival. Few studies have delineated the actual benefits of camp from the participants’ point of view. This study asked attendees to identify and rank reasons they would recommend camp attendance to a burn-injured peer.MethodsBurn-injured youth attending four regional burn camps completed a survey asking, “If you were to invite a burn survivor to burn camp how would you rate the following 10 items recently identified by your burn peers as benefits of attending'” Items included Increased Confidence, Making Friends, Help with Scarring, No Judgement Zone, Supportive Counselors, Trying New Things, Being Part of a Community, Getting Away from Home and Being Outside. Participants rated each item on a scale of 1(Not at all) to 4 (Really a lot) and then chose the 3 most important benefits they get from burn camp.ResultsParticipants (n=164) had a mean age of 13.7 years; female (n=88), male (n=74). The main cause of injury was fire/flame (40%) and scald (42%). The average age at burn was 6.1 yrs.; average years of attending camp was 4.6 and 76% had visible scars. All items received an average score of 3 or higher. The highest rated items were Increasing My Confidence (3.63) and Supportive Counselors (3.59). The lowest were, Time Away from Home (3.08) and Spending Time Outside (3.21). All items were ranked significantly higher than the two lowest ranking items (p=<001). The three responses endorsed as most important included Increasing My Confidence (46%), Making Friends-Building Connections (45%) and Helping Me Accept My Scars (44%).ConclusionsCampers endorsed many aspects of burn camp as positive. Importantly, the highest rated items support the development of meaningful relationships, which has been shown to buffer children from developmental disruption and help them adjust to trauma. The high levels of endorsement suggest that camp is helping children adjust to their burns in many ways, the key goal of burn camps.Applicability of Research to PracticeBurn care professionals should be proactive in encouraging pediatric patients to attend burn camp as it provides multiple reported benefits. Coordination between health care providers, survivors and parents in promoting attendance at burn camp is highly recommended by the very youth who espouse the benefits of attending.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.328
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 519 Development and Use of an Intraoperatively Usable Hand-Held
           Bio-Printer Delivering Mesenchymal Stem Cells In-situ
    • Authors: Eylert G; Cheng R, He S, et al.
      Abstract: IntroductionBio-Printing is a promising delivery strategy and is evolving in all disciplines in medicine including printing skin tissue and delivering cells for skin regeneration. Skin regeneration is essential for survival especially in severely burned patients. Mesenchymal stem cells (MSCs) are known for their wound healing and tissue regeneration potential, but the treatment routine and consistent delivery of these MSC represents a challenge. However, most extrusion based bioprinters are designed for in vitro use with dimensions that exceed the ones of the printed tissues, thereby limiting their clinical relevance in large area burns. We have designed and validated in vitro a novel flexible intraoperatively usable light-weight (850g) hand-held bio-printer that overcomes these limitations and shares the form factor of a dermatome. With this hand-held design it is possible to cover large surface areas with different shapes and ankles. Furthermore, this device delivers MSC directly and conformally on the wound, embeeded within an extracellular matrix layer. Our aim is to assess the functionality of this device with this intraoperatively usable system.MethodsWe conducted in vitro experiments and additional a prospective in vivo experimental large animal study, applying umbilical cord mesenchymal stem cells (UC-MSC) with a hand-held bio-printer in situ in a large full-thickness burn wound healing model, evaluating cell viability after depositioning.ResultsThe bio-printer deposit fast MSC in an precise pattern embeeded in a 0,12 mm thick stable ECM layer on the wounds. MSC survive >7 days (live/dead staining) with an overall viability of 90% in vitro. We were able to trace viable depositioned stem cell in vivo 2-3 days post-printing microscopically and with flowcytometry.ConclusionsThis easy usable new hand-held bio-printer depositions intraoperatively successful MSC onto wounds and hence bears the great potential of being an alternative of covering large burned wounds for wound healing and skin regeneration.Applicability of Research to PracticeThe data herein demonstrated that our bio-printer, engineered for the purpose of a intraoperatively cell delivery, has the ability of delivering a fairly high amount of viable cells which we were able to demonstrate in vitro, as well as in vivo considering the fact of a real scenario of cell harvesting in the morning in a laboratory, cell delivery in a syringe to the OR and real-time cell depositioning in-situ with a bio-printer on a living, moving wound healing model which needs regular bandage changes, which bears the high risk of cell-delivery failure. This supports a potential clinical trial as a next step.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.409
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 283 A Comparison of Population Characteristics and Outcomes for Acid and
           Alkaline Skin Burn Injuries in the National Burn Repository
    • Authors: Day A; McLawhorn M, Prindeze N, et al.
      Abstract: IntroductionThere is limited research comparing the patient outcomes of acid versus alkaline chemical burns. Prior literature focusing on caustic ingestion has shown higher rates of morbidity for acid ingestion compared to alkaline, however this effect has not been studied in cutaneous injury. The objective of this study was therefore to characterize the outcomes of chemical injuries based on the caustic etiology.MethodsVersion 8.0 of the National Burn Repository (NBR) was queried by ICD-9 diagnosis codes for etiologies related to chemical injury. Etiology and event descriptions were filtered to sub-classify injuries into acid and alkaline categories. Exclusion criteria were undocumented burn size, undocumented chemical etiology, inhalational or ingestion chemical injuries. Injuries involving both acid and alkaline injury were excluded. Differences between the groups were tested using non-parametric analyses. The primary endpoint of interest was mortality, while secondary outcomes included hospital length of stay (LOS) and intensive care unit (ICU) LOS.ResultsInclusion criteria were met by 2968 patients, with 797 remaining after exclusion. The patients with acid burns (n=295) were mostly male (82.5%) and Caucasian (64.9%), with an average age of 37.8±15.6 years. Most injuries were <5% TBSA (73.2%) and affected the upper extremities (38.8%). Most acid burns happened in an industrial setting (44.8%). There were 3 (1.0%) mortalities in this group. The average hospital LOS was 5.2±9.6 days and ICU LOS was 1.5±5 days. The alkaline burns (n=502) were mostly male (86.5%), Caucasian (60.7%), and average age of 38.6±16.8 years. Most injuries were <5% TBSA (69.5%) and the lower extremities were usually injured (40.9%). Most alkaline burns happened in an industrial setting (36.2%). There were 6 (1.2%) mortalities. The average hospital LOS was 5.8±7.8 days and ICU LOS was 1.8±6 days. There were no significant differences between the two groups (p>0.05).ConclusionsBased on this analysis, patients are insignificantly more likely to receive acid skin burns on their upper extremities and alkaline skin burns on their lower extremities. More patients had alkaline burns than acid burns. There was no difference in mortality or length of stay.Applicability of Research to PracticeThese findings indicate that patients with acid burns and patients with alkaline burns have similar outcomes and traits, but may have different injured body areas. As a result, outreach and education to prevent injuries should include protection methods for those areas, especially in industrial settings where most chemical injuries happen.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.201
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 70 Use of Tailored Feedback Improves Accuracy of Delirium Documentation in
           the Burn ICU: Results of a Performance Improvement Initiative
    • Authors: Gloger A; Nakonezny P, Phelan H.
      Abstract: IntroductionThe standard of care for delirium assessments in burn intensive care units (BICUs) is the CAM-ICU delirium assessment tool, but some nurses struggle with this instrument. Previous group didactic sessions in our burn unit proved to be ineffective in improving the rates at which the CAM-ICU was correctly conducted and documented by bedside nurses. This performance improvement project was undertaken to assess the impact that routine chart audits with individual, tailored feedback would have on documentation accuracy.MethodsAn accuracy goal for delirium documentation of 90% or greater was set by the burn leadership at our academic, ABA-verified burn center. The PI conducted group didactic sessions on March 1, 2017 and June 5, 2017 in which the CAM-ICU exam and its documentation were explained to the overall pool of 75 BICU registered nurses (RNs). For the pre-correctional feedback (PRE-CFB) time period of September 1, 2017 to December 31, the CAM-ICU assessment from every nurse’s shift was reviewed for accuracy by the PI with accuracy being scored as a binary “yes/no”. On January 1, 2018 an intervention was put in place in which every CAM-ICU’s incorrect performance or documentation resulted in the PI sending the offending RN feedback in the form of an email with a snapshot of their documentation, and an explanation of why it was incorrect. The post-correctional feedback (POST-CFB) time period consisted of January 1, 2018 to September 1, 2018. A Poisson regression with robust standard errors was used to compare the proportions of correct CAM-ICU documentation for the PRE-CFB and POST-CFB cohorts.ResultsThe overall rates of correct CAM-ICU documentation in the PRE-CFB cohort were 49.15% (SD=31.86), 95% confidence interval (CI): 36.43–66.31. A significant increase was seen in the rates of correct CAM-ICU documentation for the POST-CFB group [91.47% (SD=8.28), 95% CI: 87.45–95.67], p=0.0001. Notably, in the 4 months prior to the commencement of corrective feedback with every incident of incorrect documentation 0 out of 5 (0%) audits reached the 90% goal of accurate delirium documentation. In the 8 months in which corrective feedback was being given, 9 out of 15 (60%) audits reached the compliance goal set by leadership.ConclusionsUsing corrective feedback improves the accuracy of nursing delirium documentation. Further work remains to assess whether this effect will be sustainable over time or subject to decay once corrective feedback is suspended.Applicability of Research to PracticeThe ability of a burn unit to rely on the accuracy of their nursing documentation is essential when evaluating interventions to reduce delirium. If the nursing documentation is not accurate, the team will be unable to discern if their incidence of delirium has changed.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.072
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 30 Reliability and Validity of Proxy and Self-Report Scales to Measure
           Pediatric Itch Interference
    • Authors: Amtmann D; McMullen K, Bamer A, et al.
      Abstract: IntroductionPruritus after burn injury is commonly reported by pediatric burn survivors. Companion scales of proxy and self-reported itch interference for pediatric patients were recently developed using item response theory (IRT). The purpose of this study was to evaluate the reliability and validity of these measures of itch interference.MethodsThe brief scales include 4 questions and were developed by burn clinicians and researchers to assess the degree to which itch interferes with children’s activities and quality of life. Data were collected from children with moderate to severe burn injury and their parents/caregivers who participated in a multi-center national longitudinal study. Proxy and self-report items were analyzed separately, and reliability was evaluated by examining the IRT based scale information function. Known group validity analyses were completed by comparing scores by total body surface area burned (TBSA) (<40% vs ≥40%) and pain on a 0–10 item of average pain intensity (0, 1–3, 4–6, and 7–10) using analysis of variance.ResultsData from 192 children with burn injuries and 200 caregivers (91% parents; 76% female) were used. The mean age of children was 8 years (SD:5) and mean TBSA was 45% (SD:18). The pediatric sample was 54% white, 81% Hispanic, and the majority of burns were flame related (76%). Over half of the pediatric sample (56%) reported no problems with itching, while 33% reported itch interference >0.5 SD above the mean and 11% >1.0 SD above the mean. The proxy and pediatric scores were moderately correlated (r=0.63). The scales had excellent reliability (>0.9) between T-scores of 50 and 70 (self) and 49 and 80 (proxy). The scores differentiated between 4 different levels of pain intensity (self and proxy p<0.001), but not between different levels of TBSA.ConclusionsThe self-reported and proxy pediatric itch interference scales have high reliability for children or youth with average or higher levels of itch interference, and both are suitable for use in research and clinical practice. The scales are free, brief and clinically relevant measures of itch interference in children and youth with burn injury.Applicability of Research to PracticeThe scales can be administered on computer or paper. Children with itch levels >0.5 SD above the mean (33% of participants) likely warrant further evaluation for therapeutic intervention.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.034
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 380 Bromelain Based Rapid Enzymatic Debridement - Comparing Pediatric and
           Adult Clinical Trial Results
    • Authors: Shoham Y; Krieger Y, Silberstein E, et al.
      Abstract: IntroductionBromelain Based Debridement (BBD) of deep burns is approved for use in adults in Europe, Argentina, Russia, South Korea and Israel. In the US it is an investigational product in 2 multicenter RCTs (DETECT - adults, CIDS - children). The aim of this study is to compare the results of the pediatric vs adult populations in former BBD trials.MethodsMixed populations of children and adults were enrolled in 3 of 7 former BBD trials - a phase II trial, phase III trial, and a phase IIIb long term follow up trial. Phase II trial - 77 children and 77 adults suffering from deep burns were treated with BBD in a prospective, single arm, single-center trial. Data was retrospectively retrieved and analyzed for safety and efficacy of eschar removal, and need for autografting. Phase III trial - 33 children and 148 adults suffering from deep burns were treated with BBD or SOC as part of a multi-center randomized controlled trial. Seventeen children and 83 adults were treated with BBD. Sixteen children and 65 adults were treated according to the investigators’ standard of care (SOC). End points included safety, efficacy of and time to complete eschar removal, and need for surgical excision and grafting.. Phase IIIb trial - 17 children and 72 adults were available for a 2-4 year post injury long term follow-up. End points included scar evaluation by blinded assessors, need for scar modulation or reconstruction, and quality of life (QoL).ResultsPhase II trial: Pediatric results were slightly better vs adults; incidence of complete eschar removal (92% vs 91%), need for autografting after BBD (34% vs 42%), graft take (94% vs 93%), days to complete wound closure (21.4 vs 22.2). Phase III trial: In general, most of the results of BBD treated patients were significantly better than SOC patients. This BBD/SOC effect was even more pronounced in children vs adults in most parameters; incidence of complete eschar removal (100%/94% vs 88%/89%), a 9.1 vs 3.6 times reduction in the area that underwent surgical eschar removal (8%/73% vs 14%/51%), a 4.2 vs 2.2 times reduction in DPT areas that underwent autografting (6%/25% vs 9%/20%), a 2.5 vs 1.8 times reduction in blood loss, and less days to complete wound closure (30/32 vs 38/28). Phase IIIb trial: Long term MVSS scores were also in line with the more pronounced BBD/SOC effect in children vs adults (3.39/4.37 vs 3.07/3.07). There was a significant reduction in the presence of donor site scars in the overall population (40% BBD vs 68% SOC) and lower scar modulation (27.8% vs 34.3%) and reconstruction rates (3.7% vs 8.6%). QoL rates were similar.ConclusionsThe results of children treated by BBD appear to be even better than in adults. The ongoing DETECT and CIDS trials should shed more light on this issue.Applicability of Research to PracticeBBD may be a powerful debridement agent in children.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.285
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 114 Hypercoagulation and Hypermetabolism of Fibrinogen in Severely Burned
           Adults
    • Authors: Martini W; Yu Y, Wolf S, et al.
      Abstract: IntroductionTraumatic injury remains one of the leading causes of death, with coagulation dysfunction as an important contributor for the mortality. Of these, burns can result in profound metabolic deteriorations with subsequent severe loss of lean body mass. However, a comprehensive understanding of the dynamic and related changes of coagulation and metabolism after burn is lacking. This study investigated metabolic responses of plasma fibrinogen and changes of coagulation in severely burned adults.MethodsTen patients (27±4 years; 91±6kg) with 51±3% total body surface area burn were consented and enrolled into an institutional review board approved prospective study at the Burn Intensive Care Unit. On the study day (18±4 days after burn), a primed (12 µmol/kg) constant infusion of stable isotope 1-13C-phenylalanine (phe, 0.2 µmol/kg/min, 8 hours) and d5-phe (0.2 µmol/kg/min, 4 hours) was performed. During the infusion, vital signs were recorded and arterial blood samples were drawn every hour. The isotopic enrichments in blood samples were used to quantify fibrinogen synthesis rate (from 1-13C-phe infusion), fibrinogen breakdown rate and whole body protein breakdown rate (from d5-phe infusion), using gas chromatography and mass spectrometry analysis. Coagulation changes from the blood samples were measured by clinical coagulation analysis and using Thromboelastography (TEG). Ten normal healthy volunteers (37±7years; 74±5kg) were included with the same isotope infusion and blood samplings as the control group.ResultsPhysiological steady state was observed during the infusion in both groups. Burned adults had elevated heart rates (120±2 vs. 73±5 (control) beats/min), respiration rates (23±2 vs. 15±1 (control) breaths/min), plasma glucose (127±10 vs 89±2 (control) mg/dL) and fibrinogen (613±35 vs 239±17 (control) mg/dL); and reduced plasma albumin (1.3±0.2 vs. 3.7±0.1 (control) g/dL) and total protein (4.4±0.2 vs. 6.8±0.1 (control) g/dL,all p<0.05). In the burn group, the whole body protein breakdown was increased (1.8±1.1 vs. 0.6±0.0 (control) µmol/kg/min); fibrinogen breakdown was elevated (2.3±0.4 vs. 1.0±0.3 (control) µmol/kg/min); and fibrinogen synthesis rate was even more enhanced (4.4±0.7 vs. 0.7±0.2 (control) µmol/kg/min, all p<0.05). Clotting speed (TEG-alpha) and clot strength (TEG-MA) were also increased in the burn group (62±4 vs. 50±4 (control) degrees, and 76±2 vs. 56±2 (control) mm, respectively, both p<0.05).ConclusionsThe hypercoagulable state postburn is in part a result of increased fibrinogen synthesis, over and above increased fibrinogen breakdown.Applicability of Research to PracticeMany burn patients may present with increased risk of complications related to thrombosis, reflecting in part the observed changes in fibrinogen metabolism.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.115
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 230 Factors Affecting Gastric Intolerance to Enteral Nutrition in Burn
           Patients
    • Authors: Weiner B; George T, Cross J.
      Abstract: IntroductionEarly enteral nutrition (EN) provides many benefits including attenuating stress hormones and the hypermetabolic response, decreasing gut permeability, and reducing the energy and protein deficit. Timing of EN is crucial as studies have shown that delaying initiation of EN leads to intolerance of enteral feeding. Burn size has also been correlated with timing and intolerance of EN with larger burns having delayed feeding times and more gastric intolerance. The aim of this study is three-fold: to determine if there is an association between 1) burn size and gastric intolerance; 2) inhalation injury and gastric intolerance; 3) delayed initiation of enteral feeding and gastric intolerance.MethodsA retrospective study was conducted on one hundred twenty eight patients admitted to our burn center who required EN from August 2013 to June 2018. Gastric intolerance was defined by four factors: emesis, gastric residual volume >500ml, distention, and the therapeutic use of prokinetic agents. Delayed enteral feeding was defined as ≥12 hours post-admission to the hospital. Patients were grouped by presence of inhalation injury and percentage of total body surface area (<20% and ≥20% TBSA). Using SPSS, Chi Square and multiple regression analyses were performed.ResultsThe average burn size was 30%. Mean time to start EN was 16.8 hours and patients had an average of 3.2 episodes of intolerance throughout their hospitalization. %TBSA and the presence of an inhalation injury were associated with intolerance. Patients with ≥20%TBSA had one or more signs of gastric intolerance (p = 0.003). Presence of an inhalation injury was associated with two or more episodes of gastric intolerance (p = 0.043). Delayed initiation of EN was also associated with two or more episodes of gastric intolerance (p = 0.017).ConclusionsAdequate nutrition is vital for the burn patient. Larger burn size (≥20%TBSA) and inhalation injury are associated with greater gastric intolerance. Early EN (<12hrs post-admit) is associated with less gastric intolerance which allows patients to receive a greater percentage of their necessary nutrition for healing.Applicability of Research to PracticeIn patients with a burn size ≥20%TBSA and/or the presence of an inhalation injury, post-pyloric access could be considered along with early initiation of EN to reduce gastric intolerance and failure to meet the patient’s nutrition goals. <!--EndFragment-->
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.158
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 332 Topical Steroids for Suppression of Granulation Tissue in Burns:
           Results of an ABA Member Survey
    • Authors: Shoham Y; Tsur R, Krieger Y, et al.
      Abstract: IntroductionThe presence of granulation tissue in burn wounds, especially hypergranulation, may negatively influence healing time and contribute to the development of hypertrophic scarring and contractures. Topical corticosteroids have been reported to suppress the inflammatory response that contributes to the growth of granulation tissue however literature about this treatment in burns is limited. We have previously presented the results of a European Burns Association (EBA) survey about the use of topical steroids for suppression of granulation tissue in burns, where it was shown to be quite widespread (77% of responders). The aim of this study was to explore this use amongst members of the ABA, and compare it to that of the EBA.MethodsMembers of the ABA were asked to complete an online anonymous questionnaire regarding their experience with the use of topical steroids for suppression of granulation tissue in burns. The survey included questions regarding the responders’ profession and years of experience, number of patients treated yearly, experience with the use of topical steroids in burn care, and questions related to the safety and efficacy of this treatment for those experienced with its use.ResultsEighty-four questionnaires were completed by 52 physicians (62%), 23 nurses (27%), and 9 other burn care professionals (11%) with an average of 14.5 years of experience in burn care, and an average of 300 burn patients treated per year. Fifty (60%) responded they were inexperienced in the use of topical steroids for suppression of granulation tissue in burns, the major reason stated was that they were unfamiliar with this treatment option (31 of 50 responders, 62%). Thirty-four (40%) of the responders were experienced in the use of topical steroids for suppression of granulation tissue in burns. All but one of those experienced with this treatment found it safe and effective (97%). Twenty-three (68%) estimated they treated up to 30 burn patients with topical steroids per year, and 10 (29%) estimated they treated >30 patients per year. The largest area size treated varied, with most responders in the range of 1-10% TBSA, however 5 (15%) treated areas up to 11-20% TBSA, and 5 others (15%) treated areas >20% TBSA. Treatment course duration median was 5-7 days. Only 2 of the 34 experienced responders (6%) witnessed possible systemic side effects, in ≤ 1% of the patients they treated.ConclusionsThe use of topical steroids for suppression of granulation tissue in burn care appears to be quite common in the US (40%), although it is almost twice more common in Europe (77%). The vast majority of experienced users in both surveys found it a safe and effective treatment.Applicability of Research to PracticeTopical steroids for suppression of granulation tissue in burn care appear to be safe and effective.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.243
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 473 The Application of Biodegradable Temporizing Matrix in Burn
           Reconstructive Surgery: Preliminary Results of 36 cases
    • Authors: Liu X; Velamuri S, Hassouba M, et al.
      Abstract: IntroductionBiodegradable Temporizing Matrix (BTM) is a synthetic polyurethane dermal substitute which lacks synthetizing proteins and, based on the published literature, offers higher resistance to infections. BTM was applied as a dermal substitute for wound resurfacing and reconstruction. We present the preliminary results of 36 cases of BTM application in acute burn wound resurfacing and chronic complex wound reconstructive surgery.MethodsA retrospective review of BTM application with split-thickness skin grafting (STSG) in acute burn injury and chronic complex wounds over one year period at a single institution was conducted. All wounds were repaired by BTM placement and STSG in a two staged procedure. The demographic data, surgical techniques, complications and follow up results are presented in detail.ResultsThirty-six patients were evaluated. Acute burn wounds (16/36) or chronic complex wounds (20/36) with bone, joints, and tendons exposed underwent reconstructive surgery using BTM combined with STSG in a two stage procedure. There were 14 females and 22 male patients. Ages ranged from 19 to 67 years with mean age of 46.4±13.3 years. The anatomical location included head and neck (5/36), extremities (23/36), and trunk/perineum (8/36). The size of the wounds ranged from 12 cm2 to 3189 cm2 with mean 402.8± 656.2 cm2. Complications included hematoma (3/36), infection (7/36), [RV1] total BTM loss (4/36) and eyelid ectropion (3/36). Complete loss of BTM resulted from hematoma and infection. Three patients had salvage of the skin substitute using irrigation post operatively. Three cases of lower extremity wounds were not able to be salvaged and required below the knee amputations. We encountered three cases of lower eyelid ectropion in head and neck reconstructed patients. One severe case required release with skin grafting while, the other two responded to conservative measures of taping and massage. All other cases were reconstructed successfully. The follow up time was between 3 months to 15 months with mean 8.5±3.4 months.ConclusionsBiodegradeable Temporizing Matrix (BTM) may be a reliable method to resurface acute burn and chronic complex wounds. A further research study with long term follow up is needed to investigate its viable role as a dermal substitute.Applicability of Research to PracticeBTM may be used as an alternative to resurface and reconstruct burn and chronic wounds.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.367
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 430 Empowering Burn Survivors with Social Reintegration Events
    • Authors: Feichter M; Sood R.
      Abstract: IntroductionBurn injuries often affect survivors’ psychosocial functioning, including relationships and social reintegration. Resuming activities they once enjoyed or going to public places because of mobility issues and/or altered appearances can be challenging. Many fear the possibility of encountering stares, glares, questions, whispers, rejection, and/or verbal assaults. In an effort to assist burn survivors to feel more empowered, practice social reintegration skills, and reduce isolation, we developed a program whereby survivors (and their guests) are invited to attend periodic parties and social outings throughout the year.MethodsAt one of our monthly support groups, toward the end of 2015, we discussed the concept of having annual parties and periodic social outings, which resulted in positive feedback and attendees brainstormed various ideas. Once the idea list was assimilated, we began implementing periodic social outings and parties in 2016.ResultsThus far, we have conducted eight gatherings, with five being held at public venues and three in-house parties. The average number of attendance is 12.63, consisting of both survivors and guests with the smallest group consisting of 7 and the largest consisting of 20 (Table 1). Successes observed include repeat attendance by several survivors, attendees laughing and interacting with each other, expressing gratitude, giving hugs to each other, and providing positive feedback at each event. Following the events, attendees have routinely inquired about the date of the next outing and some survivors have independently gathered together to enjoy other social activities. Some of the challenges with this program include getting RSVPs; keeping the group size manageable (not too few, but not too many); managing group dynamics and ensuring no one is isolated within the group; providing transportation; and reaching more survivors.ConclusionsIn addition to support groups, implementing social events is beneficial and serves as a conduit for assisting with social reintegration skills and facilitating a sense of belongingness for burn survivors. There is often strength in numbers, and group events help to provide that sense of empowerment.Applicability of Research to Practice: n/a
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.327
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 518 Investigation of the Mechanisms Underpinning Increased Incidence of
           Cancer after Burn Injury Using Animal Models
    • Authors: Barrett L; Fear V, Waithman J, et al.
      Abstract: IntroductionRecent epidemiological studies have linked burn injury to long-term increased risk of cancer. The increased risk appears greater in female patients, however, our current understanding of the link between burn injury and lifetime cancer risk remains limited. Here, we have investigated possible links between burn injury and cancer using animal modelsMethodsWe used an established murine model of non-severe burn injury (approx. 8% total body surface area injury). At a minimum of 28 days post non-severe burn injury, mice received an injection of tumour cells (B16 melanoma tumour cells). Three different approaches were used to measure primary tumour growth, metastasis of tumours (after resection of initial tumour) and an epicutaneous cancer model to investigate tumour homeostasis and metastasis after burn. Rates of growth, metastasis number, size and location and incidence of cancer in these models was compared to non-burn injured animals. Tumour growth was measured using in vivo tracking as well as tissue sections and scanning.ResultsNo significant differences were observed in the rate of primary tumour growth. However differences in metastasis were observed between burn injured animals and controls, with rates increased in the burn injured group and different patterns of tissue metastasis emerging.ConclusionsThe data provides evidence of an impact of burn injury on metastasis of tumours. Further work to delineate the mechanisms remains necessary.Applicability of Research to PracticeIt will be important to delineate the mechanisms linking burn injury to increased cancer to reduce this lifetime burden on burn patients.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.408
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 282 Revisions in the National Burn Repository Improve Firefighter Injury
           Data Capture
    • Authors: Kahn S; Flamm T, Woods J.
      Abstract: IntroductionApproximately 60,000-70,000 firefighters suffer work related injuries per year in the United States. While most incidents are related to mechanical trauma, approximately 10% occur from burns, smoke inhalation, or heat-related injuries. Previous analyses of the National Burn Repository, the most comprehensive burn injury database of patients treated at burn centers, suggest that not all records of firefighter injuries from burn centers are being captured. The etiology of the discrepancy is multifactorial, but at least partially tied to inconsistency in selecting the patient’s occupation. In order to more thoroughly capture data, an additional field was added to the NBR in 2016, where the registrar has to designate whether or not the patient was a firefighter. The purpose of this study is to evaluate whether the revisions have increased the number of firefighters included in the NBR.MethodsThe 2016-2017 NBR was reviewed and records where the patient was reported as a firefighter were extracted and analyzed. They were compared to the data from the previous NBR analyses before the database was modified, 2002-2010. A descriptive analysis was then performed.ResultsThe revised NBR captured 102 firefighter injuries over the year, in contrast to a mean of 52.5 per year in the older data set before revisions. Thirty burn centers reported treated a firefighter injury, compared to 46 over the 9 year period of the previous analysis. Size of burn injury was captured on 68/102 patients. Of the 68 with data, 88% had an injury <10% TBSA. Six patients suffered inhalation injury. None of the patients included in the study suffered mortality.ConclusionsThe revisions in the National Burn Repository have improved the rate of firefighter injury capture in the database. Preliminary data suggests that the number of NBR records per year has doubled without an increase in total injuries across the US. However, long-term data is still lacking and this trend needs to be further studied over the course of time. When more data emerges, trends should be analyzed to develop targets for outreach, education, and preventative safety measures.Applicability of Research to PracticeFirefighters are a unique patient population that should be treated in burn centers, thus we should understand their injury statistics
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.200
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 69 Variation In Acute Resuscitation Among Pediatric 19-A-625-ABA Burn
           Centers
    • Authors: Pisano C; Fabia R, Shi J, et al.
      Abstract: IntroductionBurn management in children has improved over time, however variation in acute resuscitation practices remains. Consensus has not been established for several aspects of resuscitation, including the TBSA needed to initiate, the optimal method for estimating fluid needs, the importance of maintenance fluids, and the optimal urine output goals. These differences lead to wide variability in fluid estimates and perhaps under or over resuscitation for pediatric patients with severe thermal injury. We hypothesized that variation in acute resuscitation practices would lead to significant disparities between estimated fluid requirement and actual fluid received in 24 hours in pediatric burn centers.MethodsData from the Pediatric Injury Quality Improvement Collaborative (PIQIC) were obtained for patients with ≥ 15% TBSA burn from 8/14 to 9/18. Demographics, mechanism of injury, presence of inhalation injury, and fluid received in 24 hours were obtained from the medical record. We used each center’s resuscitation formula and Advanced Burn Life Support (ABLS) guidelines to calculate the estimated 24-hour fluid requirement for each patient and compared these values to the actual fluid received. Univariate comparisons were made using the Student’s t-Test.ResultsAmong the fifty-one patients studied, the average age was 4.4 years old (SD ± 4.3), with an average weight of 20.4 kg (SD ± 16) and an average 30% (SD ± 16.6) TBSA burn. Thirty (58.8%) patients had scald injuries, 21 (41.2%) had flame injuries and five (9.8%) had inhalation injuries. The mean fluid received in 24 hours was 6.33 ml/kg/% TBSA. Each of the five centers’ formulas and the ABLS guidelines led to different 24 hour mean fluid estimates for these patients (ABLS 5.78 ml/kg/% TBSA; 5.60 ml/kg/% TBSA; 4.53 ml/kg/% TBSA; 6.68 ml/kg/% TBSA; 5.57 ml/kg/% TBSA; and 4.92 ml/kg/% TBSA). Two centers had a statistically significant lower mean fluid estimate for 24 hours when compared with the mean fluid received (4.53 vs 6.33 ml/kg/% TBSA p=0.001) (4.92 vs 6.33 ml/kg/%TBSA p=0.003). One center had a significantly greater amount of mean fluid administered per patient in 24 hours vs two other centers (9.09 vs 5.10 ml/kg/%TBSA p=0.02 and 9.09 vs 5.13 ml/kg/%TBSA p=0.02).ConclusionsThese data show significant differences in fluid estimates and fluid received for pediatric patients with large thermal injury between burn centers. These differences may lead to under or over resuscitation for acute thermal injury of which either can lead to significant morbidity. A larger prospective study is needed to validate these results as well as examine its clinical impact.Applicability of Research to PracticeThe findings from this study along with future research may lead to a standardized best practice approach to acute pediatric burn resuscitation for severe thermal injury.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.071
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 29 The True Incidence of Inhalation Injury In Patients Referred To A
           Regional Burn Center
    • Authors: Pham C; Collier Z, Vrouwe S, et al.
      Abstract: IntroductionInhalation injury (INHI) must be rapidly diagnosed in burn patients to prevent life-threatening complications. There are many subjective signs and symptoms that suggest INHI, which may lead to misdiagnosis and intubation. We had noticed a tendency by referrers to intubate patients before confirming the diagnosis with direct visualization (e.g., bronchoscopy), resulting in misdiagnoses and possibly avoidable intubations. We sought to identify the frequency of INHI misdiagnoses and evaluate the clinical evidence used to support the diagnoses at referring hospitals.MethodsWe performed a retrospective review from July 1st, 2015 to July 1st, 2018 and included all patients intubated prior to transfer due to suspected INHI and later evaluated by bronchoscopy. Patients that were direct admissions, transferred >48 hours after the time-of-injury, or who were intubated for reasons other than suspected INHI were excluded. INHI misdiagnosis was defined as patients who were intubated prior to transfer due to suspected INHI who then had negative bronchoscopy findings (no mucosal hyperemia or sloughing, laryngotracheal edema, and/or carbonaceous deposits) and a persistent cuff leak around the endotracheal tube. Patient and burn characteristics, evidence supporting the diagnosis of INHI, and hospital outcomes were recorded.ResultsWe identified 105 patients who met inclusion criteria. Of all transferred patients intubated for suspected INHI, 66 (62.9%) patients did not have INHI on bronchoscopy and had a persistent cuff leak. Of these 66 patients, 41 (62.1%) patients were extubated within 48 hours and 25 (37.9%) required further ventilation for another reason. Both groups were frequently intubated for “low-risk” signs of INHI, with the most common being “singed nasal hairs” (34.0%), “facial burns” (25.5%), and an explosive mechanism-of-injury (MOI) (17%, home O2 explosions and e-cigarette explosions). Both groups were equivalently intubated (P>0.05) based on low and high-risk (dyspnea, stridor, etc.) signs of INHI.ConclusionsMore than half of patients intubated prior to transfer for presumed INHI were misdiagnosed. Our study did not reveal differences in the risk factors for INHI misdiagnosis, reinforcing the challenge of making the diagnosis without a direct evaluation of the airway. The development of a risk assessment tool - which incorporates MOI, patient comorbidities, and clinical exam - could improve the accuracy of INHI diagnosis by referring centers thereby avoiding intubations and unnecessary transfers.Applicability of Research to PracticeCapacity-building efforts should be targeted at referring centers to improve the accuracy of INHI diagnosis. A better understanding of low vs. high-risk signs and the development of a novel INHI risk assessment tool are needed.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.033
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 113 Effects of Exendin-4 on Pancreatic Islets Function in Treating
           Hyperglycemia Post Severe Scald Injury in Rats
    • Authors: Shen C Li D.
      Abstract: IntroductionIt has been established that Glucagon-like peptide 1 (GLP 1) inhibits pancreatic β cell apoptosis, increases insulin secretion and improves glucose tolerance in scald injury. However, the effects of Exendin-4, a long-acting incretin similar to GLP 1, remained unclear in severe scald injury. Hence, this study attempted to investigate whether Exendin-4 had similar effects by protecting the histology of pancreas in severely scalded rats.MethodsTotally 162 adult Wistar rats were equally randomized to sham burn (SB) group, burn (B) group and burn with Exendin-4 treatment (BE) group. Rats were subjected to full skin thickness scald injuries (TBSA: 50%) and were injected subcutaneously with Exendin-4 (4 μg/kg) twice daily. The histological changes of islets, the apoptosis of β cells, the amount of glucagon and insulin and the concentration of plasma glucagon and insulin were observed; and the intraperitoneal glucose tolerance test was performed as well.ResultsThe islets and β cells were injured and the number of secretory granules decreased in the scalded rats, but less histopathological changes were seen in the rats treated with Exendin-4. The apoptosis index of treated rats was significantly lower than that of the scalded rats (P<0.05). There was significant difference in β cell density post injury between the two groups (P<0.05). More insulin and less glucagon in islets and plasma was found in the treated rats (P<0.05), suggesting improved intraperitoneal glucose tolerance (P<0.05) and fasting blood glucose (P<0.05) in this group.ConclusionsBased on our previous finding that GLP-1 could control hyperglycemia by increasing insulin secretion and inhibiting β cell apoptosis in severe scald injuries, this study further confirmed that Exendin-4 could increase glycemic control following severe scald by preserving the histology of β cells in pancreatic islets and inhibiting their apoptosis.Applicability of Research to PracticeOur study provides evidence that Exendin-4 reduces histological injuries, protects pancreatic β cells from apoptosis, increases insulin synthesis and secretion, and improves glucose metabolism following severely scalded injuries. This finding can tell burn care providers how to treat hyperglycemia in a bettter manner and provider better burn care.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.114
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 379 Challenging Pediatric Cases Resulting from Train Injuries
    • Authors: Burkey B; Nanassy A, Meyer L, et al.
      Abstract: IntroductionTraumatic injuries sustained by pediatric patients involving trains result in a large number of injuries requiring high resource utilization. Prior research suggests that survivors of train accidents are likely to suffer from isolated lower extremity musculoskeletal injuries.MethodsIn the last two years, three pediatric train accident patients have presented to our center. The first patient was a 15 year old male who fell onto a live 700 volt subway track and sustained a full-thickness electrical burn to the right ankle. The second patient was a 14 year old male who attempted to jump onto a moving train, but failed and resulted in the amputation of his right lower extremity. The third patient was a 16 year old male who attempted to jump from one train to another when he came into contact with a 1200 high voltage wire, sending him 30 feet head first.ResultsThe first patient underwent multiple visits to the OR consisting of debridement, placement of a dermal regeneration template, and subsequent free flap surgery. The second patient was managed by a multidisciplinary team over the course of multiple OR visits to repair femoral vessels, revise the femur, debride the wound, myoplasty, and ultimately close the wound. The third patient’s injuries ultimately resulted in the need to amputate his left and right lower extremities and apply split thickness skin grafts to his neck, left hand, and left shoulder. Additional information surrounding the incidents, resulting injuries, clinical management, outcomes, and challenges will be discussed for each patient.ConclusionsPatients presenting to our institution have had complex traumatic and electrical injuries, as opposed to isolated musculoskeletal injuries. Hospitalizations from pediatric train accidents require an interdisciplinary approach, not just for the injury itself, but also for the ongoing support to implement changes to daily routines and provide assistance to patients and families to deal with the physical, psychological, and social challenges associated with significant physical impairment.Applicability of Research to PracticeThe three pediatric train injuries reviewed in this case report demonstrate why triage to a center providing the highest level of care is imperative. Although the literature suggests that train injury survivors are likely to suffer from musculoskeletal injuries, these cases suggest that pediatric train injuries in the urban setting are complex and likely to require multidisciplinary collaboration and high resource utilization.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.284
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 331 Delineating the Role of Serum Immunoglobulin Titers in Burn Patients
           at High Risk for Herpes Simplex Virus Infection
    • Authors: Brennan P; Wright K, Miles M, et al.
      Abstract: IntroductionHerpes simplex virus (HSV) is prevalent in the human population and reactivation of a latent infection often occurs during periods of stress, such as a serious burn injury. Previous studies have demonstrated that HSV infection complicates burn wound healing and increases morbidity. This study aimed to characterize HSV burn wound infection among high-risk patients, determine the role of serum titers in diagnosis and treatment, and describe the morbidity associated with infected burn patients.MethodsA retrospective chart review of high-risk burn patients (≥20 %TBSA and/or facial burns) who had HSV titers (HSV-1 IgG, HSV-2 IgG, and HSV-1,2 IgM) drawn from September 2015 to April 2018 was conducted. Titers were drawn for screening purposes and/or if patients developed signs of infection. Serum titers and outcomes including hospitalization and intensive care unit (ICU) length of stay (LOS) were compared between infected and non-infected patients. Active HSV infection was determined clinically based on the development of vesicular lesions. Data is reported in median (IQR).ResultsFifty-six patients had serum HSV titers measured. Titers were ordered on median hospital day 1.5 (0.00-4.0). Twenty-nine patients (52%) developed clinical signs of an active HSV infection, almost all of which (28 of 29 [97%]) also suffered facial burns. Median burn size was 20 (8.5-52.5) %TBSA in patients who developed infection vs. 24 (20-34) %TBSA in those who did not (p=0.95). In the active infection (AI) group, median HSV-1,2 IgM titers were statistically significantly higher than in the no infection (NI) group (0.71 [0.44-1.1] vs. 0.52 [0.34-0.74], p=0.02). Median HSV-1 IgG (19 [0.89-37] AI vs. 17 [0.48-33] NI, p=0.65) and HSV-2 IgG titers (0.22 [0.08-0.97] AI vs. 0.10 [0.07-5.6] NI, p=0.97) were not significant between groups. Incidence of active infection did not affect hospital LOS (27 [9.5-40] days AI vs. 20 [8.0-28] days NI, p=0.17) or ICU LOS (26 [13-49] days AI vs. 19 [11-27] days NI, p=0.09). There was no difference in mortality.ConclusionsIncreased serum HSV-1 and 2 IgM titer levels on admission were associated with an increased risk of developing active HSV infection in high-risk burn patients. IgG titers showed no correlation. Patients with facial and neck burns are at high risk for HSV infection. HSV-1 and 2 IgM titers may predict the development of active HSV infection in burn patients, but the role for screening should be further delineated in larger, prospective studies.Applicability of Research to PracticeHSV IgM serum titers may provide a screening modality in high-risk burn patients for the development of active HSV infection. Early intervention in patients with elevated titers may prevent reactivation of infection and improve burn recovery.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.242
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 517 Evaluation of the Novel Antifribotic Agent Nefopam using the Dermal
           Scratch Model in Human Volunteers
    • Authors: Tredget E; Wu J, Alpat E, et al.
      Abstract: IntroductionNefopam is a novel topical antifibrotic effective in the Red Duroc pig model. In a first antifibrotic study in humans, twenty-four (24) healthy volunteers received Nefopam applied to artificially induced bilateral dermal scratch wounds known to develop normotrophic and hypertrophic scar regions within the same lesion. Nefopam was applied and its safety and effect in reducing scar size assessed in a double blind, placebo-controlled, randomized protocol comparing Nefopam (1.0% or 3.0%) and placebo twice a day for 21 days according to GMP guidelines.MethodsSubjects were wounded under aseptic conditions using topical ELMA on each lateral hip using a jig that was 6 cm in length and 0 to 1.6 mm depth into the deep dermis of each lateral hip before receiving Nefopam or placebo cream in a blinded fashion. Digital photography POSAS, Mexameter®and ultrasound evaluations of the scar were performed on Day 6, 13, 20, 27, 48, 76, and 104. Biopsies were performed of each scar on Day 20 and 104. Expression of types I and III collagen, β-catenin target gene (AXIN-2), TGF-β1 and decorin, collagen orientation index, α-SMA and β-catenin staining in scar tissue was performed in addition to scar rating using VBSA and POSAS scales.ResultsSubjects were wounded under aseptic conditions using topical ELMA cream on each lateral hip using a jig that was 6 cm in length and 0 to 1.6 mm depth into the deep dermis of each lateral hip before receiving Nefopam or placebo cream in a blinded fashion. Digital photography POSAS, Mexameter®and ultrasound evaluations of the scar were performed on Day 6, 13, 20, 27, 48, 76, and 104. Biopsies were performed of each scar on Day 20 and 104. Expression of types I and III collagen, β-catenin target gene (AXIN-2), TGF-β1 and decorin, collagen orientation index (COI), α-SMA (smooth muscle actin) and β-catenin staining in scar tissue was performed in addition to scar rating using VBSA and POSAS scales.ConclusionsThe dermal scratch model of HTS produced bilateral symmetrical wounds with normotrophic and HT regions amenable to subjective and objective assessment of the scar therapy. It demonstrated that Nefopam did inhibit β-catenin mRNA and protein staining, but 3% Nefopam slowed the rate of healing and did not reduce scar parameters when applied during the open wound phase. Future approaches to scar therapy with Nefopam include reducing its concentration and initiating the cream during the closed wound/proliferative phase of healing to exploit its antiproliferative effects.Applicability of Research to PracticeThe scratch model is a novel approach to allow objective development of antifibrotic agents to control scar in burn and other patients.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.407
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 429 The Positive Benefits and Impacts on Social Engagement of Hospitalized
           Burn Patients Outside of their Hospital Room
    • Authors: Dines M; Cloney C, Smith T, et al.
      Abstract: IntroductionSocialization of the burn patient has been proven to have a positive impact on their overall wellbeing. Several studies have demonstrated that peer support and social interaction positively impact a patient on their journey to recovery. Of all traumatically admitted patients, the burn patient has the longest length of stay. To aid in patient recovery and lifelong success, we developed a unique program for our burn patient population, called Boredom Busters. The program evaluation focus was to examine the receptiveness of burn patients regarding socializing outside of their room with other burn patients and their families. This is a volunteer led program that offers an array of activities for patients to participate and engage with other burn patients.MethodsThis program was initiated with a grant from the hospital foundation. Grant funding was used to purchase games and supplies used during each session to engage and alleviate boredom with our patients. In addition, a secondary goal was to have patients offer support to each other in a non-threatening atmosphere (similar to SOAR). Specific activity and attendance were recorded during each session to satisfy the requirement of the grant. A program evaluation was utilized to examine the various activities, the patient attendance, and to study the efficacy of this program as a tool for recovery.ResultsThe program has been active for ten months and has averaged 3 patients per session [0-9 patient participants]. Both the average and the median patient attendance compared to the unit daily census was 21%. With the encouragement of patient visitor participation, our median total attendance per session was 4.92 participants [0-12 total participants]. Our volunteer staff running each session ranged from 1-3 volunteers, depending on the complexity of the session’s activity.ConclusionsStructured, regularly occurring social gatherings are integral for a burn patient’s recovery while hospitalized. While attendance has remained fairly consistent across this program’s time frame, patient’s spirits are visibly lifted while they are engaged and focused on an activity rather than their injury. Expanding the success of the program will require continued multidisciplinary promotion and adaptation to the current unit culture. Further research will be done to look at the association with the Boredom Busters program and patient Acute Stress Disorder/Post Traumatic Stress Disorder scores in the future.Applicability of Research to PracticeThis would be applicable to any hospitalized burn patient.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.326
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 281 Developing LIBRE Profile Levels: Providing Clinical Meaning for Scores
    • Authors: Ryan C; Schneider J, Slavin M, et al.
      Abstract: IntroductionThe Life Impact Burn Recovery Evaluation (LIBRE) Profile is an innovative patient reported outcome measure. The LIBRE Profile uses a computerized adaptive testing approach to assess social participation and reintegration among adult burn survivors (injuries with total body surface area (TBSA) burned ≥5% or burn to hands, feet, face, or genitals). LIBRE Profile scores yield a metric score for each of the six domains; however, it is difficult to interpret these scores without context. This study implemented a staging/bookmarking process to determine numeric cut-points that identify different levels of social participation for each LIBRE Profile domain with accompanying narrative descriptions for each level.MethodsA mixed-methods approach involving four components was implemented: 1) quantitative synthesis of LIBRE calibration data to create item maps for the six LIBRE Profile domains; 2) convene an expert panel (6 burn survivors, 6 researchers, 4 clinicians) and use a modified Delphi approach to identify cut points for different LIBRE Profile levels and develop initial narrative descriptions for each level; 3) conduct ANOVAs and post-hoc comparisons to examine differences between mean scores for identified LIBRE Profile levels; 4) complete qualitative analyses to finalize narrative descriptions.ResultsInitial LIBRE Profile level cut points and narrative descriptions, independently established by expert panelists, were reviewed and refined during an in-person meeting. At the end of the meeting, four levels for the Social Activities, Social Interactions, Romantic Relationships, Sexual Relationships, and Work and Employment domains and five levels for the Relationships with Family and Friends domain were established. ANOVA results demonstrated significant differences between mean values for all levels for each domain (p<0.05), except Relationships with Family and Friends. Since no significant difference was found between Levels 1 (LIBRE Profile Scores ≤ 18) and 2 (LIBRE Profile Scores 19-30), these levels were collapsed to yield a single Level 1. The new cut points and draft narrative descriptions were integrated into a web-based survey sent to the expert panelists. Based on survey responses, revisions were made to yield final cut points and narrative descriptions for each level.ConclusionsCut points with accompanying narrative descriptions were established for each LIBRE Profile domain. The validity of these levels and narrative descriptions will be established in future work.Applicability of Research to PracticeLIBRE Profile levels and narrative descriptions can be used by burn survivors, clinicians, researchers, and peer support leaders to better understand, interpret, and use LIBRE Profile scores to enhance a burn survivor’s social recovery post-burn injury.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.199
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 68 The Role of Social Work in U.S. Burn Centers
    • Authors: Abrams T; Lloyd A.
      Abstract: IntroductionSocial workers have played an important part on burn teams for decades, yet there has been a paucity of research defining their role across U.S. burn centers. To advance professional standing, social workers would benefit from a universal definition of their contributions to and advocacy for burn patients, families, communities and other team members.MethodsAn online survey was developed and sent to 78 U.S. burn centers, inquiring about SW demographics, degree/licensure, roles/responsibilities, post-graduate training, if undergraduate/graduate trauma courses should include burns, membership in ABA and/or NASW, and if SW skills were fully utilized.ResultsOf the 78 surveys sent, 32 were returned, one respondent declined to participate (n=31). Respondents’ ages ranged between 26 to 63, were mostly female (90%), Caucasian (93%), African American (3%), or other (4%). Respondents held an MSW (97%) or PhD (3%). The majority held SW licensure (87%), including LCSW (46%), LISW, LMSW, and LSW (12%), LAPSW (4%), and other (15%). Respondents identified roles and responsibilities as discharge planning (79%), case management (67%), patient counseling/therapy (72%), family counseling/therapy (69%), support group facilitation (41%), community education/outreach (38%), school re-entry programs (21%), back-to-work programs (10%), burn prevention programs (14%), other (24%), as well as duties in units other than the burn center (65%). More than half of respondents (55%) strongly agreed or agreed that their MSW program had prepared them for working in a burn center, followed by LCSW’s (24%), LISW’s (6%), LSW’s (26%), and LMSW’s (6%). More than half of respondents (69%) agreed or strongly agreed that burn trauma should be included in graduate curricula, 28% agreed or strongly agreed that it should be included at the undergraduate level. Less than half of respondents (48%) had attended post-graduate education focused on burn trauma, almost (70%) felt their position fully utilized their SW skills and professional affiliations were ABA (31%) and NASW (14%).ConclusionsDespite tremendous growth in burn care, there has been little effort to formally define the roles and responsibilities of social workers as part of the burn team. Responsibilities varied across burn centers, making it impossible to define best practice. In addition, greater understanding of roles and responsibilities by academics would provide valuable insight when developing SW curricula and post-graduate education to better prepare SW practitioners.Applicability of Research to PracticeSocial Work is an integral part of the burn team. Development of formalized micro, mezzo and macro level roles and responsibilities of social workers across the burn care community and informed academic curricula would improve professional training for burn trauma social workers.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.070
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 112 Microangiography: An Alternative Tool for Assessing Severe Frostbite
           Injury
    • Authors: Lacey A; Masters T, Punjabi G, et al.
      Abstract: IntroductionAssessment of frostbite injury typically relies on angiography or nuclear medicine to detect perfusion deficits prior to thrombolytic therapy. However, many centers lack rapid access to these modalities. The aim of this study was to evaluate the potential of a novel imaging method, microangiography, in the assessment of severe frostbite injury.MethodsPatients with severe frostbite were included if they received a post-thrombolytic Technetium-99 bone scan, a Technetium-99 bone scan without thrombolytic therapy, or microangiograpy study to affected limb(s): Tc99 scan alone (N=64), microangiography alone (N=21) and both Tc99 and microangiography (N=22). All imaging modalities were compared post-thrombolytic therapy (when applicable). Perfusion deficits and amputation levels were scored using the Hennepin Frostbite Score.ResultsThe majority of patients received thrombolytic therapy (77%) and the average time to thrombolytics was 6.7 hours. Tc99 scans showed good correlation with amputation level (r=0.785, P<0.001). Microangiography showed strong positive correlation with amputation level (r=0.856, P<0.001). In comparison of the Tc99 scan and microangiography in patients with both scans (N=22), we observed significant differences in the mean scores of perfusion deficit (z=3.20, P=0.001). In this same cohort, no correlation was found between level of perfusion deficit on Tc-99 bone scan and amputation level (r=0.175, P=0.449). A very strong positive correlation was found between the microangiography studies and the amputation level (r=0.910, P<0.001).ConclusionsThese results demonstrate a microangiograpy as a reliable alternative method of assessing severe frostbite injury and predicting amputation level. Microangiography has the potential for use in assessment of eligibility for thrombolytic therapy.Applicability of Research to PracticeMicroangiography provides a safe method of definitive frostbite diagnosis.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.113
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 229 Application of Burn Nurse Competencies to Burn Center Education
    • Authors: Yukon K; Cyrulik M, O’Connor A.
      Abstract: IntroductionAt our academic medical center, we provide nursing education annually to validate nursing competency in critical care. In addition to the annual nursing education, the Burn Center nursing staff is provided burn specific competencies. Also provided are in-services and simulations throughout the year which include high risk, low volume scenarios. The Burn Nurse Competency Initiative (BNCI) at the American Burn Association (ABA) developed nursing competencies to ensure standard competent care is provided to all burn patients.MethodsDuring our competency planning session, we utilized the competency domains developed by the BNCI to plan the skills stations, testing and didactic information. We were able to validate our Burn Center nurses on 17 of the 45 competency statements by proving the essential performance criterion was achieved. Of the 17 statements, we had at least one from each of the 11 domains.ResultsThe nursing burn staff was able to demonstrate competence in all skill stations. They completed the didactic portion of our competency day. The essential performance criterion from each competency statement was validated by the written exam and the activities completed.ConclusionsThe burn nurse competencies created by the BNCI were essential in completing our burn specific competency day. Our future competency sessions will contain the competency statements we did not cover the year prior. The end goal is to provide all domains and their statements in the ABA burn nurse competencies within a three year period.Applicability of Research to PracticeEncourage the promotion, advancement and recognition of Burn Nurses within the nursing field.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.157
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 472 Clinical Evidence of Burn Wound Infection in the Pediatric Population:
           A Quality-Improvement Initiative
    • Authors: Gus E; Zuccaro J, Fish J.
      Abstract: IntroductionIn order to provide appropriate burn care to the pediatric population, our pediatric burn center has a sedation program in place. Whilst some patients are sedated for burn wound treatment at the initial presentation, others have it done in up to 72 hours postburn. It is not clear whether the timing of the first burn wound treatment has an influence on the rate of infection. Thus, the objective of this quality-improvement project was to assess the infection rates of pediatric burn patients that underwent the initial procedure on presentation or up to 72 hours later.MethodsThe health records of 160 pediatric burn patients who received acute burn care at our pediatric burn center between July 2017 and June 2018 were reviewed in this quality-improvement study. Patients were divided into two groups: “immediate” if the first burn wound treatment occurred at presentation, and “delayed” if it was done between 24 and 72 hours postburn. Infection occurring between presentation and complete healing of wounds or skin grafts was defined by the presence of one or more of the following signs or symptoms: hyperemia, increasing pain, lymphangitis, fever, purulent discharge, malaise, anorexia, hyperglycemia, leukopenia or thrombocytopenia. The infection rates and the relative risk were calculated and the Pearson Chi-square test was used for statistical analysis. A value of p<0.05 was considered statistically significant.ResultsThe average age was 39.7 months and 105/160 (65.6%) sustained scald burns. Twenty-six patients (16.2%) had a diagnosis of infection. In the immediate group, 11/80 patients (13.8%) showed signs of infection, whilst 15/80 patients (18.8%) satisfied the infection criteria in the delayed group. The relative risk of infection in the immediate group was 0.73, which was not statistically significant (p>0.05).ConclusionsWe can conclude that there was no difference between the infection rates of patients who received the first wound treatment in an immediate way, as compared to those who underwent the procedure between 24 and 72 hours postburn.Applicability of Research to PracticeA larger study based on this project is being conducted to support its findings. If the additional resources allocated for prompt sedation programs can be avoided, our and other burn centers may eliminate additional costs without detriment to the patients.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.366
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 330 Automating the Characterization of Burn Injuries for Pre-Hospital Care
    • Authors: Argenta C; Rule G, Serio-Melvin M, et al.
      Abstract: IntroductionOptimal pre-hospital burn care is crucial for avoiding complications and improving outcomes of patients. Therefore, it is critical to make a rapid, accurate assessment of a patient’s percent total body surface area burned (%TBSA) for triage, burn fluid resuscitation, evacuation and resource planning. Often inexperienced clinicians grossly over or under estimate burn wound size. This is of particular importance during a mass casualty disaster when there could be hundreds-to-thousands of burn victims who require transfer to a burn center.MethodsThe objective of our study is to fully automate the process of assessing %TBSA by analyzing data from multiple visible, infrared and depth sensor images. Our goal is to produce an enhanced Lund and Browder (eLB) that maps the image data to a full body representation that reflects the actual patient morphology and captures the burned area accurately. We identified, tested, evaluated and analyzed numerous cameras and image processing techniques to help establish a minimal suite of necessary imaging techniques. To standardize admission photo data collection, we developed a set of patient pose templates that ensure near 100% image coverage over the surface of the skin, provide sufficient context for orientation, and can be used in the clinical setting to image the patient in a standardized way, without unnecessary discomfort.ResultsWe have successfully used our handheld prototypes to image thermal wounds and human volunteers in order to extract 3D models of skin surfaces from complex scenes, using machine learning. We are in the process of combining images for the eLB, approximating burn depth, and evaluating the %TBSA from the source images.ConclusionsWhen complete, the automated generation of an eLB promises to make patient imaging robust and repeatable by prehospital personnel. However, using computer vision in a real world clinical setting is challenging. We address these challenges while building towards a future system that will be suitable for use in urban, rural and austere settings, especially during mass casualty disasters.Applicability of Research to PracticeThe development of an eLB may increase the accuracy at which non-experts can assess %TBSA, potentially saving money by preventing unnecessary transfers to burn centers, especially during mass casualty situations when burn centers could be overwhelmed.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.241
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 377 Burn Intensive Care Unit Mock Code: Training that Makes a Difference
    • Authors: Gruber M; Ayers S, Gorisek R, et al.
      Abstract: IntroductionMock simulation for cardiac arrest (Code Blue) and patient admissions is beneficial and improves burn team skill level and team communication. Mock simulation codes and mock simulation admission education was implemented on a 21 bed, adult and pediatric, Burn Intensive Care Unit. Burn Team members requested reinstatement of mock simulation codes and the addition of mock simulation admission education, as an adjunct to routine ACLS and PALS training, since ACLS and PALS training are non-specific to burn team roles and formal classes only occur once every two years.MethodsSimulation scenarios were implemented randomly across multiple shifts and times. ACLS algorithms were utilized but tailored to specific burn care scenarios. Likert Scale surveys were anonymously given to the multidisciplinary team following the mock admission simulations to evaluate confidence levels, and areas for improvement. A debriefing was held after every simulation. For the mock code events, a more detailed simulation sheet was used to assess time to initiate compressions, quality of compressions, time to application of pads, time to first shock, time to first medication administration, role determination, and quality of communication between group members.ResultsSubjective data were collected from the Likert Scale regarding confidence levels, areas for improvement and best practice areas. Staff were satisfied to have the hands-on experience to practice skills amongst their burn team members. There was a positive response to increasing performance confidence levels. There was a positive response to increasing teamwork. Staff were also able to learn and become more familiar with location of supplies, procedural kits, the code cart, and the defibrillator. The objective data for the mock code simulations is currently being collected. There will be 8 simulations for the mock codes. Follow up data will be available after the simulations study is completed.ConclusionsStaff felt a stronger sense of teamwork, there was an increase in confidence levels in emergency situations, and staff knew where to locate necessary supplies in a high stress situation. Results will be determined for the mock code events after the simulations have taken place.Applicability of Research to PracticePatient outcomes depend on the skills and knowledge of their providers, and the level of teamwork and communication between those providers. Mock admissions and mock codes have given providers the opportunity to practice, in a simulated setting, through hands-on skills and team building. This specific multidisciplinary simulation created by burn nursing leadership provides the unique skills and characteristics needed to provide emergent care for the burn population.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.283
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 28 A Quality Improvement Project to Tighten Discharge Opioid Prescribing
    • Authors: Friedstat J; Levin J, Sangji N, et al.
      Abstract: IntroductionSince both burn injuries and their treatment—operative and non-operative— are intensely painful, burn care providers routinely use opioids in the care of their patients. While such use is appropriate, there is increasing recognition that opioids should be carefully titrated to each patient’s pain and that the course of opioid treatment should be as short as possible. In this context, we examined prescribing practices in our burn unit. Finding wide variation in discharge opioid prescribing, we conducted focused staff surveys to assess opinion regarding inconsistencies in prescribing practice. Following the surveys, we instituted a practice change. We then compared discharge opioid scripts before and after the change. Here we present the results of this quality improvement project.MethodsWe created a detailed flowsheet showing every step in the process of inpatient pain treatment with narcotics. We then surveyed the nursing staff who identified the most prominent underlying issues to be communication and regular consideration of analgesic needs. Consequently, we instituted daily discussion of each patient’s pain on morning rounds, reviewing opioid use in the previous 24 hours, current pain assessment, and considering barriers to weaning. With IRB approval we retrospectively assessed opioid discharge quantity before and after this practice change (in morphine equivalents per day until first follow up) for all adult patients discharged to home.ResultsIn the four months prior to practice intervention we prescribed an average of 38 morphine milligram equivalents (MME) per day (SEM 2.8 MME/day). Over a 4 month period beginning 3 months after our practice change we prescribed an average of 28 MME/day (SEM 2.1 MME/day), representing a decrease of 27% in mean discharge opioids per day until first follow up. This practice change resulted in a significantly (p< 0.05) lower MME/day.ConclusionsMeasures taken to understand and reduce practice variation in opioid prescribing can be effective, promoting adequate analgesia while reducing the risk of substance dependence and diversion.Applicability of Research to PracticeThe methods we used to assess and improve consistency in opioid prescribing were effective and may be effective in other burn centers.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.032
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 428 Bitter Cold: The Impact of Frostbite on Vulnerable Populations
    • Authors: Stewart J; Goodman L, Rabbitts A, et al.
      Abstract: IntroductionBitter cold and exceptionally low wind chill factors marked the first two weeks of 2018 in the Northeast Corridor. On January 1, the National Weather Service tweeted “Arctic air mass will bring a prolonged period of much-below-normal temperatures and dangerously cold wind chills to the central and eastern US over the next week.” The purpose of this review was to examine the demographic profile and psychosocial histories of all patients admitted to the burn service who sustained frostbite injuries during this period of abnormally cold weather.MethodsWe performed a retrospective chart review of the eleven patients admitted to our center between the dates of 1/1/2018 and 1/15/2018 with frostbite injuries. Data collected included: age, gender, race, LOS, insurance status, immigration status, housing status, history of dementia, diagnosis of serious and active mental illness, history of substance abuse, and presence of ETOH or other drugs at time of admission. Data are presented as mean ± SEM (range).ResultsThe charts of eleven patients were analyzed (6 males). The average age and TBSA were 46 ± 5.7 years (25-80 years) and 3.0 ± 1.2% (1.25-6.0%) respectively. LOS was 25 ± 8.0 days (2-73 days). Racial representation was 55% Black, 36% Hispanic, and 9% White. Substance abuse was documented in the histories of seven of the patients (64%). Notably, of these seven, five presented to either our ED or an OSH under the influence of ETOH or other drugs. History of dementia or active mental illness was documented in 64% of the cases. Housing was precarious for two out of three patients in this population with 32% of the patients experiencing unstable housing arrangements and 36% qualifying as fully un-domiciled. Insurance coverage varied: 9% having commercial/private insurance, 55% Medicare/Medicaid, and 36% being uninsured. Additionally, 36% of the patients were undocumented immigrants.ConclusionsWhile the sample size is small and more research is needed, this data indicates the need for an increased attentiveness to the prevention of frostbite injuries that emphasizes community outreach and partnership with homeless shelters, places of worship, community centers, and emergency food programs. Frostbite prevention efforts should align with current fire safety educational initiatives and resources. The intensive medical and multidisciplinary resources required to support frostbite patients medically, socially, spiritually, and emotionally underscores the need for prevention, education, and advocacy targeted to vulnerable populations and communities most affected by the frigid weather.Applicability of Research to Practice: Directly applicable
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.325
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 516 Determination of Adequate Debridement of Burn Wounds via Laser Speckle
           Imaging
    • Authors: Stone R; II, Larson D, Wall J, et al.
      Abstract: IntroductionThe current standard of care for burn wound management involves removal of necrotic tissue to a bleeding wound bed then application of a skin graft depending on the depth of injury. However, the debridement procedure is difficult, time consuming, and can result in graft failure and hypertrophic scarring if performed inadequately. The purpose of this study was to determine if laser speckle imaging could be utilized to image the debrided wound beds prior to grafting to determine if adequate debridement was performed.MethodsDeep partial and full thickness 5x5 cm burn wounds were created on the dorsum of six anesthetized Yorkshire pigs using appropriate pain control methods. After 4 days, the necrotic eschar was debrided via a dermatome to three depths (0.030”, 0.060”, 0.090”), a meshed split thickness skin graft was applied, and graft success (defined as >70% graft take) was assessed on days 7 and 14. Laser speckle imaging, which measures blood flow, was captured for all wounds pre-burn, post-burn, pre-debridement, and post-debridement.ResultsApproximately 65% of wounds with the least debridement amount resulted in graft failure. No differences in bacterial counts were detected in the post-debrided wounds. Laser speckle imaging indicated no differences in the burn contact times immediately post-burn but significant differences were detected at the pre-debridement time point when comparing the burn depths. After combining all wounds into either graft success vs. failure, laser speckle imaging detected a significantly higher blood flow in post-debrided wounds for the wound beds that resulted in graft success.ConclusionsThis study confirmed the clinical situation of inadequate debridement as a contributor of graft failure. Bacterial colony forming unit counts ruled out infection as a possibility for the wounds that resulted in graft failure. More importantly, laser speckle imaging was able to differentiate between the wounds that were adequately debrided and those where necrotic tissue remained; thereby, providing clinicians with a non-invasive technique that could help determine when to graft.Applicability of Research to PracticeNon-invasive imaging technologies that can determine if adequate debridement has been achieved would aid clinicians on identifying the best time to graft a wound.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.406
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 111 10 Years of Clinical Experience Using Point of Care Non Cultured
           Autologous Skin Cell Suspension
    • Authors: Fear M; Wood F.
      Abstract: IntroductionTime to healing is a key driver of scar outcome in the repair of skin post burn injury. Autologous skin cell suspension has facilitated early intervention or wound healing in isolation in partial thickness injuries and in combination with traditional techniques in deeper injuries with limited donor sites. The aim of the presentation is the analysis of the impact of the introduction of cell based therapies into a clinical model of care in a health system providing burn care to a population of 2.5 millionMethodsThe data captured prospectively from the point of injury to the 1 year follow up was analysed retrospectively. A comprehensive data base has been well established to include the injury details, interventions and an outcome battery considering functional psychological and aesthetic outcomes at multiple time points. The data was subject to a data hack process followed by in-depth data analytics using 1.2 million rows of data points.ResultsIn a 10 year period the cell based therapy technique was used in 3500 cases, 9% scar revision, 90% acute burn injury and 1% miscellaneous wounds. Of the cases requiring surgical intervention 12% received SSG alone, 48% SSG and cells and 40% cells alone. The use of cell therapies was associated with a reduction in the number of surgical procedures, with earlier intervention and reduction in time to healing and length of stay. When using a cumulative outcome index the intervention within 1 week of injury was associated with significant improvement at 3 months which was maintained at 1 year post injury.ConclusionsCell based therapies are associated with earlier intervention and associated reduction in scarring and measurable improvement in outcomes. Since evolving from cultured epithelial autograft sheets to suspension in 1995 then onto non cultured skin cell suspension in 1998, the use of skin cell therapies has become integrated into the standard of care.Applicability of Research to PracticeThe results need to be taken in the context of a comprehensive model of care which focuses on every intervention from the time of injury to optimise marginal gains along the clinical pathway.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.112
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 280 Implementation of a State Wide Burn Care and Mass Casualty Course
           (BCMCC)
    • Authors: Newman (Matherly A; McCulley K, Lewis G.
      Abstract: IntroductionBurn Centers represent a small but vital component of the healthcare community with less than 1,900 burn beds nationwide. These specialty care centers are typically located in urban areas, leaving rural areas without access to burn expertise. While burn disasters are somewhat rare, even a relatively small incident can overwhelm local hospitals due to the resource needs and clinical expertise required.Our state identified the need for a multidisciplinary burn disaster training course for all healthcare regions, recognizing the scarcity of burn resource access. We further identified a gap in disaster management after the initial care and management taught by burn outreach programs through Advanced Burn Life Support. The aim of this study is to describe the Burn Care and Mass Casualty Course (BCMCC).MethodsThe Burn Center in partnership with the State Department of Health collaborated with healthcare coalition leaders in order to improve first responder and first receiver readiness. We developed an eight hour structured course which consisted of two clinical tracks. One was specific to providers who worked in a healthcare facility and the other a field track for first responders. Both contained applicable burn specific care and scenario based case discussions. Following a networking lunch, the two groups combined to review current response plans, resources and partnerships from the federal to the local level. The course culminated in a two-hour table top learning simulation which was customized to the area’s largest identified hazard and vulnerability threat. The course was continually updated based on course evaluations and participant verbal feedback.ResultsThe BCMCC was taught in all seven regional coalition locations, providing local training to rural EMS and healthcare clinicians who often lack specialized medical training opportunities in their communities. In total 236 participants were educated, students included physicians, nurses, EMS providers, private sector response teams, outpatient clinicians, health department and safety/security personnel. The largest number of participants occurred in urban areas, with the smallest from more rural regions. Physicians were noted to comprise the smallest number of attendees which correlates with existing literature on clinician engagement in disaster preparedness initiatives.ConclusionsThe BCMCC provides an inter-professional approach to disaster emergency response, while enhancing provider everyday care and providing partnership and network opportunities.Applicability of Research to PracticeAvailability of burn care access and expertise will remain an issue. The BCMCC seeks to bridge the gap between urban and rural access making it applicable across broader regions nationally and internationally.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.198
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 471 Impact of a Therapy Dog Program on Burn Center Patients and Staff
    • Authors: Pruskowski K; Gurney J, Cancio L.
      Abstract: IntroductionThe benefits and healing power of the human-animal relationship have long been recognized. Animal-assisted activities (AAA) and animal-assisted therapy (AAT) programs have been implemented in both inpatient and outpatient settings and have demonstrated positive outcomes on patients’ moods, anxiety levels, pain scores, and rehabilitation efforts. AAA/AAT also has a positive impact on nursing and hospital staff. Given the burnout risk in highly stressful inpatient settings, AAA/AAT may decrease burnout by improving morale. The development of a canine AAA/AAT program has not been previously reported in any burn center.MethodsA therapy canine AAA/AAT program was established at our burn center in November of 2017 with the intent of improving duration and quality of rehabilitation sessions and physical therapy. Initially, therapy dogs only worked with patients during rehabilitation sessions in the in- or out-patient gyms (AAT). After 5 months, the program expanded and therapy dogs were allowed to visit inpatients and staff on the ward or in the ICU (AAA). Patient and staff interaction with the therapy dogs was voluntary. Satisfaction surveys were distributed to patients and staff members to evaluate the respondents’ satisfaction with the therapy dog session and to examine the impact of therapy dog visits on pain, anxiety, and mood.ResultsAt the 9-month point, 13 patient surveys and 22 staff surveys were collected. Patients worked with the therapy dogs in all environments of the burn center: outpatient (n=4), ward (n=7), and ICU (n=2). All patients were satisfied or very satisfied with the dogs’ participation during the session. Eleven (84.6%) patients agreed or strongly agreed that their pain and/or anxiety was improved after working with the therapy dogs. All patients reported that they would like more sessions with the therapy dogs. All staff members were satisfied or very satisfied with their therapy dog visit and all enjoyed having the therapy dogs present. Twenty-two (95.7%) staff members reported an improved mood after seeing the therapy dogs. Twenty-two members (95.7%) reported that they would like to see the therapy dogs again.ConclusionsNine months after the implementation of the therapy dog program, we have demonstrated feasibility of this type of program at this Burn Center patients and staff were satisfied with the therapy dogs’ visits and reported wanting additional sessions with the therapy dogs. Given the importance of rehabilitation in the recovery of burn patients, further investigation into this integrative therapy should be performed and longer term outcomes assessed.Applicability of Research to PracticeStaff and patient desire to work with therapy dogs may reduce burnout, increase morale, and may improve patient rehabilitation.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.365
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 376 Review of Ceftolozane-Tazobactam (C/T) Use in Burn Patients
    • Authors: Quan A; Zmarlicka M, Matthews M, et al.
      Abstract: IntroductionInfections are a significant contributor to mortality and morbidity as well as increased length of stay in burn patients. The Society of Critical Care guidelines identify sepsis as a medical emergency; delays in appropriate antimicrobial therapy are associated with increases in mortality and poor outcomes. Immunosuppression, long hospital stays, and damaged protective skin barrier frequently contribute to infectious complications in thermally injured patients. Repeated exposure to antimicrobials can lead to the development of antibiotic-resistant microorganisms. This case series describes the first published use of ceftolozane-tazobactam (C/T), a novel cephalosporin and beta-lactamase inhibitor combination agent, in burn patients.MethodsThis is a case series of seven patients treated with C/T.ResultsA total of 9 courses of therapy were given, with 2 patients receiving 2 courses each. Indications for use included bacteremia (5/9 cases) and pneumonia (4/9 cases). The most common dosing regimen utilized was 3g intravenously administered every 8 hours with each dose infused over 60 minutes. Six out of 9 courses were used for definitive therapy, with 3 courses being de-escalated based on culture sensitivities. Of the 9 total courses, in 6 instances, patients were receiving continuous renal replacement therapy (CRRT) at the initiation of therapy; 4 were receiving C/T definitively, and 2 were receiving C/T empirically. In all patients receiving C/T for definitive therapy, the causative organism was Pseudomonas aeruginosa. Minimum inhibitory concentrations (MICs) of the isolates ranged from 0.38 to 3 mcg/mL, with the MIC50 and MIC90 being 1.25 mcg/ml and 2.25 mcg/ml, respectively. Of the patients receiving C/T for definitive therapy, all infections were deemed to have clinically resolved; 1 out of 6 patients receiving C/T definitively expired due to reasons unrelated to the Pseudomonas infection requiring C/T.ConclusionsWhile there is an ongoing clinical trial to address C/T kinetics and optimal dosing in the burn population, there is currently a lack of data to guide use of C/T in such a setting. Additionally, there is a paucity of data describing optimal dosing of C/T in patients undergoing CRRT. This case series provides real-world data on the successful use of C/T in the burn population.Applicability of Research to PracticeThis case series is the first description of successful use of C/T in the burn population and offers additional insight into use of C/T in patients with CRRT.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.282
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 329 Prognostic Indicators for Upper and Lower Extremity Amputations in a
           Verified Burn Center
    • Authors: Matthews M; Richards N, Elebrashi Y, et al.
      Abstract: IntroductionPatients with burns or necrotizing soft tissue infections are at risk for significant morbidity. Extremities with extensive complex skin defects are at increased jeopardy. This may be increased by co-morbid conditions, yet prognostic indicators are not well defined in the literature. The purpose of this study was to identify and describe those potential prognostic factors found in the burn population patients requiring either upper or lower extremity amputation.MethodsThis is a retrospective chart review of patients requiring amputation from 2000 - 2017. The co-morbidities of these patients were compared to patients that did not require amputation. Descriptive statistics and the relative risk of amputation for certain co-morbidities were calculated.ResultsDuring the study period there were a total of 110 patients requiring amputation versus 12,997 that did not. For those requiring amputations, burn injury was the most common precipitating event (59%) and flame flash was the most common mechanism (25%). The most frequent level of amputation was at the digit level (39%) followed by the transtibial level (33%). When amputees (AP) were compared to non-amputees (NA) there were significant differences between average (median) age, AP 49.9 (54.1) years vs. NA 34.3 (33.8) years (p < 0.001), TBSA AP 19.9% (6%) vs. NA 8.1% (4%, p=0.003) and length of stay AP 33.4 (26) days vs. NA 11.0 (7) days (p<0.001). Conditions associated with increased risk of amputation included cardiovascular disease (RR 4.3, p<0.001), liver disease (RR 4.8, p<0.001), renal insufficiency (RR 19.1, p<0.001), diabetes (RR 5.0, p <0.001), alcohol abuse (RR4.3, p<0.001) and smoking history (RR 4.1, p<0.001).ConclusionsSeveral comorbidities are associated with higher risk of amputation. Burn patients at higher risk of amputation are not only systematically different from non-amputees, but more specifically have greater restriction of blood flow from diabetes, cardiovascular disease and end stage renal disease which are the greatest afflictions leading to the need for an amputation. Future studies should investigate the role of circumferential burn injury, escharotomies / fasciotomies, as well as, the differences in amputation level between the upper versus lower extremity.Applicability of Research to PracticeThis study gives providers quantified data to identify those patients at higher risk of amputation.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.240
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 27 Prescribing Patterns of Pharmacologic Sleep Agents Following the
           Implementation of a Sleep Protocol in Adult Burn Patients
    • Authors: Walroth T; Switzer A, Spera L, et al.
      Abstract: IntroductionSleep disturbances in burn patients can prolong recovery, cause psychological and physiological stress, and put patients at risk for additional complications. A gap exists in the literature regarding optimal pharmacologic sleep agents in burn patients. In September 2014, a sleep protocol was introduced in our burn center to promote sleep-wake cycles through use of non-pharmacologic interventions and pharmacologic agents. Our study objective was to assess sleep protocol implementation and its effects on prescribing patterns of pharmacologic sleep agents in adult burn patients.MethodsThis retrospective review evaluated outcomes of a sleep protocol in adult patients admitted for burn or inhalational injury between 10/1/16 and 8/31/17. Exclusion criteria were active psychological disorders, pregnancy, or incarceration. The primary outcome was the prescribing pattern of pharmacologic sleep agents (e.g., medication class, name, dose). Secondary outcomes included non-pharmacologic interventions and assessment/documentation of sleep.ResultsOf 242 patients admitted during the study period, 76 (31%) received first- or second-line sleep agents for pharmacologic intervention as defined by the protocol. Of those, 40 met inclusion criteria. Patient demographics are listed in Table 1. Of the included patients who received pharmacologic treatment, 34 (85%) received first-line medications according to the protocol (p<0.001). 78% received melatonin and 38% received trazodone vs. diphenhydramine (18%) or other agents (15%); p<0.001. Non-pharmacologic recommendations were provided in 3 (8%) patients and were documented as completed in 0 patients. Physicians (45%) and physical/occupational therapists (45%) provided documentation regarding sleep most commonly, while nurses reported in 15% of patients.ConclusionsIdentified areas for improvement include: protocol adherence, non-pharmacologic interventions, medication dosing, and sleep documentation. A phase two study is underway to develop and validate a standardized tool to objectively assess sleep, educate regarding non-pharmacologic interventions and documentation, and evaluate the effect of these items on prescribing of pharmacologic agents for sleep.Applicability of Research to PracticeTo our knowledge, no previously published literature exists evaluating prescribing patterns of pharmacologic sleep agents or a sleep protocol in adult burn patients.Patient DemographicsParameterResults (N = 40)Age (years), median (SD)53 (20)Male, n (%)32 (80)Caucasian, n (%)36 (90)History of sleep disorder, n (%)5 (13)Presence of inhalation injury, n (%)4 (10)Thermal injury, n (%)33 (83)%TBSA, median (IQR)11 (4,21)Length of stay (days), median (IQR)14 (6,23)Number of sleep medications, median (IQR)1 (1,2)
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.031
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 427 Prevalence and Risk Factors for Posttraumatic Stress Disorder after
           Burn Injury
    • Authors: Nosanov L; Prindeze N, Clemente L, et al.
      Abstract: IntroductionAfter burn injury, patients can struggle psychologically in addition to issues with physical function and cosmesis. Posttraumatic stress disorder (PTSD) is a known sequela of burn injury, with a suggested frequency of 18-33%. However objective measures of injury have not been reliably linked to the development of symptoms, making routine identification a challenge. The objective of this study to identify patient characteristics associated with a positive PTSD screening exam in the outpatient setting.MethodsThe Primary Care Posttraumatic Stress Disorder screening questionnaire (PC-PTSD-4) was administered to patients at their initial outpatient clinic visit at a large regional Burn Center over a four month period of May-October 2018. Patients excluded included those with dermatologic disorders, known history of PTSD and repeat questionnaires. Patient demographics, injury mechanism, total body surface area (TBSA) involvement and questionnaire results were recorded. Patients were considered screen positive if they responded affirmatively to at least three of the four questions. Chi-square and student’s t-tests were used to compare patients with positive and negative screens. Further evaluation assessed the sub-population that answered affirmatively to all four screening questions.Results188 surveys were answered in total, with 182 remaining for analysis after exclusions. Patients had a mean age of 41.8±15.5 years, mean TBSA of 4.5±7.5%, with equal gender distribution. 6.6% of questionnaires were completed in Spanish. The most common injury etiologies included scald (24.2%), flame (24.2%) and grease burns (20.3%). Positive screens were noted in 48 patients (26.4%), with 30 of these patients responding affirmatively to all four questions, and 83 with negative responses to all questions. The only significant predictor for a positive screen was increased total TBSA% (4.0±5.6 vs 6.0±11.2, p = 0.004). A similar finding was noted when examining patients with four affirmative responses (p < 0.001).ConclusionsAlthough all patients are susceptible to PTSD after burn injury, positive screening correlates with larger initial injury. Future directions of this project will evaluate additional factors including concurrent traumatic injuries, prior psychiatric history and the presence of assault.Applicability of Research to PracticeEarly identification of at-risk individuals enables expedited efforts to provide education and support.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.324
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 515 A Novel Hand-Held Bioprinter Enhances Skin Regenration and Wound
           Healing in a Burn Porcine Model
    • Authors: Eylert G; Cheng R, He S, et al.
      Abstract: IntroductionSkin regeneration after a severe burn injury is crucial for survival. Current treatment options are limited. Mesenchymal Stem Cells (MSCs) are known to promote wound healing and tissue regeneration but delivery of these cells remains a challenge. Bioprinting represents a promising delivery strategy. We have designed, validated in vitro as well as in a large animal wound healing model a novel intraoperatively usable hand-held bio-printer, that delivers MSCs directly and conformally onto wounds, embedded within an extracellular matrix layer. Aim: Determine postburn skin wound regeneration after MSC deposition with a novel intraoperatively usable bioprinter.MethodsWe conducted a study in a full-thickness porcine burn wound model where we in situ delivered umbilical cord mesenchymal stem cells (UC-MSC) conformally via our hand-held bio-printer. An acellular collagen-based dressing that is the clinical gold standard was seeded with MSC and used as a control. Wound healing and skin regeneration were determined at day 28 (remodeling) and followed until day 49 (maturation) post-intervention for full tissue remodeling assessment.ResultsOur data (day 28) show accelerated wound healing after stem cell application, with significantly increased collagen regeneration (<p=0.05, ANOVA) compared to controls, as well as increased neovascularization (<p=0.05, T-Test) and less contracture formation (<p=0.01, T-Test) compared to acellular control. Overall, wounds treated with 3D printed MSCs appear with enhanced wound healing compared to acellular controls and can compete in some analyzed skin regeneration aspects with our equal used established cellularized control.ConclusionsThis novel hand-bio-printer deposits stem cells directly onto wounds which has significant potential for burn patients to enhance skin regeneration and improve wound healing.Applicability of Research to PracticeThe data herein demonstrated in our large living animal study which is comparable in wound healing to humans, show that bio-printing of mesenchymal stem cells enhance wound healing significantly thus supporting the next step for a clinical trial.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.405
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 279 Association of Personal Protective Equipment Use and Maintenance with
           Burn Injury: A Pilot Survey of Firefighters
    • Authors: McLawhorn M; Flamm T, Woods J, et al.
      Abstract: IntroductionThermal injury remains a persistent occupational hazard for both volunteer and career firefighters. While advances in personal protective equipment (PPE) offer improved safety and reported rates of compliance are high, injuries still occur. The purpose of this pilot project was to investigate the correlation between PPE use and damage with injury characteristics.MethodsA structured questionnaire was distributed to a convenience sample of firefighters undergoing initial outpatient evaluation in a burn clinic. Data were collected regarding fire experience, incident circumstances and extent of injury sustained, as well as PPE use and post-injury damage and PPE integrity monitoring history. Chi-square tests were used to evaluate the relationship between PPE use, damage and monitoring with injury.ResultsThere were 45 respondents included in this analysis. Firefighters were on average 31.8 ± 7.5 years with 10.8 ± 8.9 mean years of experience (range 1-32 years). The majority of respondents identified as career firefighters (72.4%). Injuries were sustained primarily in structure fires (93.3%), and 22.0% were in a training setting. Ears were the most commonly burned area (n=25) followed by arms, hands, and wrists. Nearly all injuries were small (< 5% TBSA) and managed in an outpatient setting. Only one patient requiring grafting, though 60.0% reported missing at least one shift. The majority reported use of most PPE elements at the time of injury, although more than 25% indicated not using suspenders. Eight individuals had not been sized for PPE in the last two years, two of whom indicated never having been properly sized. Although ear burns were not significantly associated with use of helmets or earflaps, there was a significant association with helmet damage (p = 0.04), with a trend toward significance for visible gear damage (p = 0.05) and hood damage (p = 0.09). Arm burns were significantly associated with visibly damaged gear (p = 0.003), damaged gloves (p = 0.012), and damaged coats (p < 0.001).ConclusionsGiven the association of PPE damage and injury identified in this pilot study, further training directed towards improved frequency of resizing and inspection of PPE post-injury may be warranted. These findings necessitate further investigation, which is planned via more extensive questionnaire distribution within the firefighting community. Further significant associations may be revealed within a larger sample size.Applicability of Research to PracticeThermal injury will continue to be an occupational hazard for firefighters. Better understanding of associated factors can help target training and prevention strategies to mitigate risk.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.197
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 67 Inter-Hospital Variation of Inpatient versus Outpatient Pediatric Burn
           Treatment after Emergency Department Evaluation
    • Authors: Garcia D; Cina R, Corrigan C, et al.
      Abstract: IntroductionPediatric burns are significant source of injury in this country with an estimated 160,000 pediatric burns a year treated in the United States. Approaches to burn care in the pediatric population are highly variable and can be targeted as a potential measure in quality improvement. We hypothesized that institutions vary significantly in their allocation of treatment of small (<10%) burns to either inpatient or outpatient care.MethodsWe performed a query of the PHIS database for fiscal year 2017 to quantify small pediatric burn admissions and Emergency Department (ED) visits and analyze associated costs. The ICD-10 code T31.0 was used to identify burns involving less than 10% of total body surface area (TBSA).ResultsWe queried the PHIS database of 39 children’s hospitals included. Of these, 25 hospitals admitted patients either for care of <10% burns, with an average of 84±76 ED evaluations per hospital (range: 6–371). While 72% of total burns across institutions were treated as outpatient with 12% and 16% observation and inpatient admissions respectively, this was not distributed evenly across hospitals. Some hospitals admitted as many as 81% of small burn patients while admission rates were as low as 0 - 4%. When analyzed with respect to outpatient burn care, a bimodal distribution was observed distinguishing two groups: high hospital utilizers with an average of 30% outpatient burn care and low utilizers averaging 87%. Total ED charges per institution averaged $118,280 (range: $5,945- 501,444), with median charges per patient of $1,420 (range $471–2,540). A significant increase in cost was noted with inpatient care with total charges averaging $1,380,679 (range: $9,475 - 5,509,286). Median inpatient charge per patient was $47,766 (range: $8,235–273,839) which is a greater than 33-fold increased cost per patient compared to outpatient treatment.ConclusionsSignificant variation was observed in regards to inpatient versus outpatient pediatric burn treatment in small (<10% TBSA) burns. Compared to outpatient burn care, observational and inpatient burn care are significantly more costly. Implementing protocols and personnel to provide adequate attention to small burns in the ED could be an important cost-saving measure.Applicability of Research to PracticeThis study identifies different institutional patterns of admission practices with regard to pediatric burns can help identify areas for developing a more cost-effective approach.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.069
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 228 Situational Simulation Training Course for New Nurses
    • Authors: Zhang Y.
      Abstract: Introduction“New nurses” in hospital means the nurses who were born in 90s last century. They had received high quality public education. They are the only child in their family. They have huge difference from last generation in life style and work style. Senior and experienced nurses always found it was bemused to tell them how to care the extensive when new nurses come to burn center. For improving the clinical ability of new nurses, the staffs in nursing department of burn center designed a course of Situational Simulation Training Course(SSTC) for new nurses in management of critical care such as fluid resuscitation, respiratory management, management of pediatric burn or neonate burn et al. Then we evaluate the clinical ability of them.MethodsThe course was designed by brainstorming method. And we focused on the management of critical situation such as: fluid resuscitation, respiratory management, management of pediatric burn or neonate burn et al. The clinical principles, emergency cases integrate in the course. And senior nurses and young nurses or new nurses discuses and manage the artificial modes togetherResultsThe expert consultation authority coefficient is Cr=0.88, and the expert judges the coefficient of variation of the feasibility of the case design to be <0.2. Finally, the clinical simulation teaching case of the nursing related to the fluid resuscitation period of the critical burn patients is constructed. The case structure consists of eight modules: including teaching arrangements, teacher maps, medical records, learning objectives (student goals and mentor goals), simulation scenario settings, role play, item preparation, mentor summary discussion feedback.ConclusionsSituational simulation training course for new nurses is a skillful course for new nurse in teaching them the basic abilities in management of fluid resuscitation and respiratory problem.Applicability of Research to Practice: Critical care education
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.156
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 470 The Advanced Burn Provider Course: Early Results from an
           Evidenced-Based Curriculum
    • Authors: Carter J; Johnson J, Holmes IV J, et al.
      Abstract: IntroductionBurn care and medical education has undergone dramatic change with clinical innovations, medical simulation, and curriculum design. Trauma has over 7 courses while burns has one, Advanced Burn Life Support. Our goal was to develop a course with an evidenced-based curriculum and novel simulators to meet the needs of healthcare professionals that require more advanced training.MethodsFollowing IRB approval, a 360-degree REDCap™ survey was distributed using a 5-point Likert scale with free text to: physicians, nurses, therapists, administrators, and survivors. A 360-survey was selected due to the multi-disciplinary aspect of burn injury management and the recognized expertise of non-physicians. The survey assessed participants’ perceived proficiency of providers managing adult and pediatric patients and was evaluated by a multi-institutional panel of recognized professionals in medical education and burn care. Procedure simulators were developed following the survey and subsequently validated and published. Course design incorporated adult learning theory with discussion-based sessions separated by hands-on skills labs. An after-course survey of participants was distributed with a 5-point Likert scale and free text.ResultsA total of 109 individuals participated with a 58% response rate and a diverse response pool: 34.5% physicians/advanced practice providers (APP), 33% nurses, 23% burn therapists, and 10% burn survivors, administrators, or social workers. Survey results by burn physicians/APP demonstrated the lowest self-rated proficiency scores at managing large pediatric burn injuries and frostbite while non-physicians reported developing wound treatment algorithms, performing an escharotomy, and aftercare/reintegration. The first course had 18 participants and incorporated a biomimetic escharotomy simulator. The after-course survey of participants noted a 100% agreed the course improved their understanding of managing burn injuries, improved their ability to troubleshoot, improved confidence to manage a patient up to 96 hours, and would recommend the course to a peer. 0% of the participants identified excessive industry bias.ConclusionsProviding burn care beyond the initial assessment and stabilization requires additional skills and knowledge. Providers that are challenged to provide this care may benefit from additional training. Further work is being invested to develop disaster management skills, assessment components, and determine course validity.Applicability of Research to PracticeThis research may serve to broadly impact burn education and on-boarding of providers.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.364
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 110 Fighting A New Front On An Old Battlefield: Examining the Development
           of Topical Antimicrobial Care to Control Burn Wound Sepsis
    • Authors: Tejiram S; Shupp J.
      Abstract: IntroductionRecognition of septicemia from burn wounds as a major cause of morbidity and mortality has profoundly changed the management of burn wound infection and its associated septic complications. The development of effective topical antimicrobial therapy is one of the last major developments of modern burn care and has been driven by major world events and scientific breakthroughs.Approaches to topical burn wound management have changed throughout the centuries. In ancient civilizations, for example, philosophers like Hippocrates and Aristotle described the use of various oils, fats, and acids to treat wounds. Modern topical burn care can be traced back to World War I when the prevailing “toxemia” theory attributed post-burn death to toxic substance release from the burn wound. It would not be until the late 1930s before this theory would be challenged and an infection model would be employed.The next major advancement in topical antimicrobial burn care came during World War II. The lack of established topical antimicrobial burn care protocols in part lead to the federal development of the Subcommittees on Surgical Infections and Burns, who would later help establish national protocols on topical antimicrobial burn care.The 1960’s brought Moyer’s successful use of dilute 0.5% silver nitrate solution in burn wounds while researchers like Fox described the benefit of silver sulfadiazine use in a scalded mouse model inoculated with Pseudomonas aeruginosa. Perhaps most exciting was Pruitt’s dramatic improvement in post-burn mortality with the use of topical mafenide acetate in burn wounds.ConclusionsTopical antimicrobial use in burn care has been driven by scientific breakthroughs and major world events. It has played a dramatic role in reducing morbidity and mortality from burn wound infection. It is prudent that we look to the past as we seek to improve burn care and learn from the wisdom of those who most significantly advanced the control of burn wound infection.Applicability of Research to PracticeNote: This work is edited down in size from the original 2018 ABA History Manuscript abstract application for this formal submission.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.111
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 373 Injury Patterns in Combined Trauma and Burn Patients
    • Authors: Hard J; Smith T, Wagner A, et al.
      Abstract: IntroductionBurn patients with associated trauma pose added complexity in management due to potential for hemorrhage and multi organ system dysfunction due to injury. Recent studies suggest that this unique population experiences an increased mortality, as compared to burn patients alone. However, most studies on combined burn-trauma patients have been conducted in the setting of war, and civilian data are sparse with focus on motor vehicle crashes (MVCs). We sought to characterize specific injury patterns in the civilian burn-trauma patient.MethodsA retrospective review was conducted at our ABA verified burn center of all patients admitted for burn injury with concomitant trauma from July of 2015 through June of 2018. Those patients who died within 24 hours of admission were excluded. Data collection included demographics, percentage of total body surface area (% TBSA) burned, type of trauma, organ system involvement, pattern of injury, operative care, length of hospital stay (LOS), and major complications.ResultsIn total, 1139 patients were reviewed with 40 patients (3.5% of burn admits) having combined burn-trauma. The median age was 39 years (range 13-87), median % TBSA burned 5 (range 0.2-84%). Mortality was 7.5% (n=3). Blunt trauma was the most common mechanism, 92.5% (n=37) with following distribution: MVC (40%, n=16), falls (32%, n=12), explosion/blast (12.5%, n=5), automobile vs pedestrian (8%%, n=3) and one crush by heavy machinery. Only three patients had penetrating injury (7.5%), whose mechanism included two stabbings and one dog bite.Spinal fracture was the most common injury seen in both MVCs (44%, n=7), and explosions (80%, n=4). Intra-cranial injury was most commonly seen in falls at 50% (n=6). Specific injury pattern breakdown is noted in Figure 1. One third of patients (n=13, 33%) were taken to the operating room for their traumatic injuries. Of these, the most common was orthopedic surgery (n=7, 54%), including pelvic fixation, intra-medullary nailing of long bones, and amputations.ConclusionsCombined burn-trauma injuries are not common. Blunt trauma resulting in skeletal injury appears to be the most common injury pattern. Orthopedic surgery is the most common trauma related surgery performed.Applicability of Research to PracticePractitioners should be aware of specific injury patterns based on mechanism in order to avoid missed injuries.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.281
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 26 The Influence of Laser Doppler Imaging on the Clinical Judgment of
           Different Health Professionals on the Management of Indeterminate Depth
           Burn Wounds Images
    • Authors: Asif M; Modica A, Chin A, et al.
      Abstract: IntroductionIn this time of uprising telemedicine and digital health communications, photo images are often used to make preliminary assessments of burn severity and need for further management. The reliability of making a preliminary clinical assessment based on photo images is often poor, but we explore how additional information from laser Doppler imaging (LDI) can influence the clinical assessment of digital images. The aim of this study was to investigate the accuracy of burn wound images and influence of LDI to determine the need for surgical management among different healthcare providers in 100 indeterminate depth burn wounds.MethodsA controlled pre-test/post-test survey was conducted at a burn center to assess the influence of LDI on the clinical judgment of physicians (Group 1), nurses and physician assistants (Group 2), and other health professionals (Group 3) of whether a burn wound needed surgical or non-surgical management. The survey consisted of regular digital photographs of 100 burn wounds for the pre-test, and the same images side-by-side with 100 LDI color-coded images for the post-test. Relative risk, ANOVA, paired t-test, and intention-to-treat was used for analysis. A p value ≤ 0.05 was considered significant.ResultsA total of 6000 grader-image interactions were analyzed. There was a significant difference in the scores for pre-LDI and post-LDI surveys when all graders were considered (51.93 +/- 7.02 vs 72.87 +/- 7.93; p < 0.0001). On average, the post-LDI score was 20.9 points higher than the pre-LDI score (95% CI [17.388, 24.478]). The post-LDI assessment was 1.4 times (RR = 1.4, CI 1.12–1.75) more likely to correctly predict the need for excision and skin grafting than the pre-LDI assessment alone. All professional groups had an improved performance post-LDI: Group 1, 51.89 +/- 7.45 vs 76.44 +/- 5; Group 2, 52.07 +/- 6.08 vs 72.71 +/- 7.67; and Group 3, 51.71 +/- 9.17 vs 68.57 +/- 10.11 - no statistical difference was observed between groups (p = 0.92).ConclusionsColor-coded LDI images aid the clinical judgment of digital images significantly. For every five LDI evaluation performed, one assessor had their treatment plan modified as a result of the LDI. Our study shows that digital images are unreliable in predicting burn severity and need for surgical management. LDI images can be a great supplemental tool to digital photos to increase its accuracy of determining the severity of burn wounds.Applicability of Research to PracticeDigital images are unreliable in predicting burn severity. LDI images can be a great supplemental tool to digital images to increase its accuracy of determining the severity of burn wounds.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.030
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 326 Early Therapy Experience with NovoSorb™ BTM
    • Authors: Klotz T; Heath K, Schmitt B, et al.
      Abstract: IntroductionSince 2014, Biodegradable Temporising Matrix (BTM) has been used at our center to treat specific deep burn wounds.1 Currently patients are treated in line with standard therapy protocols. As a new dermal substitute for the treatment of burn injury, the implication for the use of this product on anticipated rehabilitation times, therapy pathways and scar management compared to previous standard treatment is unknown. Our aim was to map the pattern of recovery following BTM application compared to a historic matched burn cohort.MethodsPatients who have received BTM as part of their surgical burn wound management were identified from existing department records. Matched, retrospective cohort patients were identified based on burn size (total body surface area (TBSA)), depth, age and gender from our burn registry database. No exclusion criteria were applied. BTM site, time post BTM application to commence range of motion (ROM), mobilisation, maximal ROM, scar management requirements and duration, scar outcome, incidence of reconstructive surgery, and length of intensive care and hospital stay were collected.ResultsTwenty one patients (15 male, 6 female; mean age 39.3 years) admitted with burn injuries averaging 40.25% TBSA (34.27% TBSA full thickness) and treated with BTM were included in this this review. Historical matched patients represented an average of 60.3% TBSA burn injury (37.3% TBSA full thickness). Average length of stay = 88.72days in the BTM group and 84.7 days in the matched group. To date, nine patients have completed 12 month follow-up with the Patient and Observer Scar Assessment Scale (POSAS) and Matching Assessment of Scars and Photographs (MAPS) assessments. Mean POSAS scores for the observer component were comparable to published data, whilst mean patient scores were less. Pain and itch scores for scar sites were below those expected.ConclusionsThe use of BTM following deep burn injury comparatively decreases the amount of scar management, rehabilitation and reconstructive surgery required. The pattern of recovery following BTM and subsequent therapy care pathway recommendations will be presented. Current results indicate improved patient outcomes regarding pain, itch and time to ROM.Applicability of Research to PracticeChanges in surgical practice have altered acute and reconstructive surgical pathways. This has resulted in changes to rehabilitation therapy following severe burns in our unit. Ongoing evaluation of clinical practice and implementation into practice is required to ensure optimal patient outcomes are achieved.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.239
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 426 Are we our own Worst Enemies' PTSD Symptoms Secondary to
           Intrahospital Course
    • Authors: Simmons E; Unuvar M, Patel D, et al.
      Abstract: IntroductionThe management of the cosmetic and physiological derangements in burn patients has significantly evolved over the past decades leading to an increase in survival rates. Despite these advances, stress disorders are relatively common and remain challenging issues in burn patients. Events occurring during the intrahospital management may contribute to development of these disorders in burn patients, but this has not been well studied.MethodsThis is a retrospective case series of three patients evaluated by the burn psychologist at our medical center who identified PTSD symptom content related specifically to intrahospital events.ResultsThe first patient is a 28 year old female with a history of depression who sustained 35% TBSA flame burn from an apartment fire. She was taken to the OR on multiple occasions for excision and debridement and skin grafting throughout her admission. Ketamine was administered for pain control during dressing changes. She reported nightmares after discharge in which the content included hallucinations she experienced during ketamine administration. The second patient is a 30 year old female with a history of anxiety and depression treated at an outside hospital for SJS/TENS who presented to our medical center burn clinic for outpatient follow-up care. She was referred for psychotherapy for PTSD symptoms. She reported daily nightmares, mostly related to hallucinations while administered ketamine for pain control during hospitalization. The third patient is a 45 year old male with no psychiatric history who sustained 10% TBSA flame burns during a propane tank explosion. He was treated inpatient and underwent repeated debridement and dressing changes. During the course of psychotherapy, he identified peak periods of distress when recounting memories of the debridement and dressing changes, as well as recurrent intrusive memories of the debridement that interfered with sleep initiation.ConclusionsThis case series identified patients who cited events related to the intrahospital course as the content of some PTSD symptoms in sessions with the psychologist. Themes of nightmares related to ketamine hallucinations and distress associated with intrusive memories of pain during dressing changes emerged.Applicability of Research to PracticeThese findings support that providers should continue to be aware of the importance of adequate pain control during dressing changes, as well as potential psychiatric sequelae of using analgesics with dissociative amnestic properties.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.323
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 514 Effect of Topical Platelet Rich Plasma on Burn Healing After Partial
           Thickness Burn Injury
    • Authors: Minori N; Tarigan U, Buchari F, et al.
      Abstract: IntroductionBurn injury has direct impact on local and systemic changes. Many modalities for wound bed preparation was not satisfied. One of the most progressive dressing nowadays is PRP. PRP induces the synthesis of collagen with fibroblast. PRP accelerates wound healing and decrease the use of skin graft.MethodsSixty Wistar albino rats were divided into 3 groups of 20 rats each. Group 1 (platelet-rich plasma group) was exposed to burn injury and topical platelet-rich plasma was applied. Group 2 (control group) was exposed to burn injury and normal saline was applied. Group 3 (blood donor group) was used as blood donors for platelet-rich plasma. Wound was excised on the fourteenth day then fixated in 10% formaldehyde. Specimen was then embedded in parafin block and stained with HE to observe the number of PMN and Masson’s Trichrome to observe collagen deposition.ResultsCollagen deposition was found significantly higher in Group 1 (platelet-rich plasma group) (P<0.05). The number of PMN is significantly less in Group 1 (P<0.05) meaning topical PRP also has anti-inflammatory effect.ConclusionsPRP is proven to accelerate burn healing after partial thickness burn injury by increasing the number of collagen deposition also having anti-inflammatory effect shown by the significantly less number of PMN in PRP group.Applicability of Research to PracticePRP as a new method of burn wound dressing may be able to accelerate wound healing. In large burn area, PRP might help in decreasing the use of skin graft.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.404
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 66 Laser Treatments for Burn Scars - 6 year Experience
    • Authors: Blome-Eberwein S; Gogal C, Boorse D, et al.
      Abstract: IntroductionAfter showing efficacy of fractional photothermolysis in improving physiologic function in burn scars in 2012, we have treated adult and pediatric patients with burn scars on a regular basis. Safety and morbidity of these treatments in large patient series have not sufficiently been documented.Methods1876 fractional ablative and non-ablative laser treatments were studied in form of a retrospective chart review. Complications of the treatment itself and of the anesthesia associated with treatments, as well as the frequency of treatments, the energy applied per cm2, the size of the scars treated in each session and the Vancouver and POSAS scales were documented.Results414 patients, 238 male and 176 female, 308 adults, 106 children, were included. See table 1 for demographics. All patients had received the standard scar treatments prior to laser. A total of 1876, 1116 ablative fractional and 652 non-ablative fractional laser treatments were performed and 108 other (IPL, Q-switched).The average size of scar treated was 565 cm2 in each session. The average energy applied per cm2 was 6.5 Joule. The median time between wound healing and first laser treatment was 150 days. 4 treatments were performed on each patient on average (8 weeks apart). Deep sedation/anesthesia was used in 1207 treatments, local anesthesia was used in 535 treatments and no anesthesia was used in 134 treatments (mostly IPL). There were 26 (2.1%) anesthesia complications, nausea and prolonged recovery. No serious anesthesia complication was reported. 26 (1.38%) post treatment complications were reported, 12 blister formations, 1 open area (non-ablative laser), 13 prolonged itching, none of which required further intervention. The average initial Vancouver scar scale (VSS) was 10.16, POSAS was 36.66. The available final VSS improvement was 1.4points, POSAS was 15.5 pointsConclusionsFractional laser treatments for hypertrophic and symptomatic burn scars are safe and effective in the adult and pediatric population, independent of skin type.The most common complication was nausea post anesthesia. There were no post-laser infections or skin rashes noted in our study population.Applicability of Research to Practice: ImmediatePatient demographicsTotalPediatricAdultPatients (n)414106308Age33.28.141.9Male23870168Female17636140Caucasian32875252African American30822Asian American12210Other/mixed442024Initial Burn size %TBSA15.715.6515.79Skin grafting initially24358185
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.068
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 372 Fusarium in a Burn Center: Lessons Learned
    • Authors: Gabehart K; Roggy D, Sood R.
      Abstract: IntroductionFungal infections in burn patients are not uncommon related to large TBSA injuries, immunosuppression, and challenges with nutrition. In March of 2017, our burn center experienced a trend of positive quantitative wound cultures for Fusarium in four different patients. Here, we share our approach to this outbreak and the changes to our practice as a result of this incidence.MethodsA multidisciplinary team to include medical leadership, nursing leadership, PT/OT, rehabilitation, EVS, quality/risk, facilities and infection control was formed to investigate. All four patients were cohorted in a closed environment on our burn unit and received 1:1 care until discharge. Through architectural design of our burn center we were able to remain open during this time to accept new patients. From March 20-April 11th the entire burn center was terminally cleaned to include all direct and indirect patient care areas. Air quality testing and surface testing was completed by an outside company to look for a Fusarium source. The team met daily to communicate progress and findings. All cleaning practices, infection control protocols and workflow processes were reviewed.ResultsAll air quality and environmental surface cultures were negative for Fusarium and no firm source was identified. One consistent denominator was all operations were performed in the same room although on different days so energy around OR terminal cleaning and culturing was an initial focus. With a focus on wound as a primary source we evaluated our workflow practices as it related to wound cleansing, dressings, surface cleaning including beds, and overall contact of ancillary devices touching the wounds such as cables and splints. The financial impact was substantial totaling 1.3 million dollars. These charges include the room and board cost for the patient, increase in salaries paid due to the need for 1:1 care for four patients, and the environmental testing of the entire burn center. Three patients survived and one expired. All were treated systemically, topically and underwent serial debridements as necessary for source control.ConclusionsOur leadership took a proactive approach to review practices and investigate processes as a result of this infectious outbreak. A variety of processes were reviewed and changed as a result of our review. These processes include but are not limited to: enhanced terminal and daily cleaning practices of patient rooms, equipment and operating rooms, weekly leadership rounds with infection control practitioners, and increased preventative maintenance of patient rooms. This experience enhanced our awareness and allowed opportunity for us to find improvements in our daily workflow practices and cleaning strategies. Since July 2017 we have had no further cultures test positive for Fusarium in any source.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.280
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 25 Overutilization of Helicopter Transport in Smaller Burns - A Healthcare
           System Problem that Should be Corrected
    • Authors: Roman J; Shank W, Demirjian J, et al.
      Abstract: IntroductionEighty eight percent of all patients burned in North America suffer burns of less than 20% TBSA. These patients may need care at a burn center, but do not necessarily require emergent helicopter transport (HEMS). We sought to identify a cohort of patients suffering smaller burns who do not benefit from HEMS to establish significant health care system savings.MethodsA five-year retrospective analysis of prospectively collected data from consecutive patients was performed. Patients were separated into two groups: HEMS and ground transport (EMS). A sub-analysis was performed between those with smaller burns, (<20% TBSA and no ICU/OR requirement). ED disposition, hospital length of stay, distance transported and cost was analyzed.ResultsOf 616 burn patients presenting to our center, 13% were transported by HEMS, 46% by ambulance, and 61% by private vehicle. Of those transported via HEMS, 38% had been evaluated and treated at an outside hospital prior to transfer. Patients transported via HEMS had larger burns (13 vs. 9 %TBSA; p = 0.002) and deeper burns (p < 0.001), longer hospital stays (p = 0.003), higher ICU admission rates (p < 0.001), and mortality rates (p = 0.003) compared to those transported by EMS. Transport distance was a mean 5.5 times greater (88 vs. 16 mi) in the HEMS group (p < 0.001). Within this cohort, 53% of patients transported via HEMS suffered smaller burns, compared to 73% transported by EMS. A sub-analysis of the smaller burns cohort showed increased distances of transport via HEMS (91 vs. 18 mi; p <0.001) and increased rates of admission from the ED in the EMS group (93% vs. 68% by HEMS; p = 0.005) yet no difference in length of stay, or rates of early discharge, defined as <24 hr hospital stay. Fully 1/4 of those transported via HEMS with smaller burns were discharged from the ED after burn consultation, debridement and dressing. Mortality in both was nil. Average cost per helicopter transport was $29K.ConclusionsAccurate triage and burn center consultation prior to scene transport or hospital transfer could help identify patients not benefiting from HEMS yet safely transferrable by ground, or better served by early clinic follow up, which would reduce cost without compromising care in this cohort.Applicability of Research to PracticeAnnual institutional savings of >$444K could be multiplied manyfold were non HEMS transport universally adopted for smaller burns.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.029
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 469 Treatment of Non-Life Threatening Burns: Where Does Your Partner
           Prefer Your Donor Site'
    • Authors: Parizh D; O’Sullivan G, Houng A.
      Abstract: IntroductionBurn injury can result in severe life altering deformities, and greatly impact the lives of our patients. Even if the TBSA injured is not life threatening on its own, the day to day lives of burn victims change as they face the cosmetic consequences of their injury. This subgroup of burns is often managed on a semi-elective basis, and donor site preference comes into the discussion during the surgical consent process. In our practice the two areas that we feel can be sufficient to harvest a donor site to treat a 2% TBSA burn are the lateral hip and buttock. We feel that these cosmetically conscious areas can be hidden discretely, and are reasonably accessible in the supine, prone and lateral recumbent positions. The expectant donor site morbidity of the additional scar is difficult to explain to our patients. We decided to conduct a survey of burn care professionals, who are well versed in donor site morbidity, on their donor site preference.MethodsAn online survey was conducted amongst burn care professionals through the American Burn Association from June through July of 2018. A donation to the Phoenix Society for Burn Survivors was made for every survey completed. The survey was anonymous and open to: surgeons, advance care providers, nurses, residents and fellows, physical therapists and patient care technicians. Inclusion criteria required that the person was familiar with what a healed donor site looked like. The donor sites offered were: lateral hip, buttock, site not listed, and no preference. Data collected included: age, sex, ethnicity, region in USA that they live in, occupation, where they would prefer the donor site on themselves, and where they would prefer the donor site on their partners.ResultsA total of 263 responses were recorded. The majority of our responders were female, 64% (n=168). Age varied and was evenly distributed. Majority of the responders were white and scattered evenly through the USA. The occupational distribution included: 33% attending surgeons, 40% nurses, remainder was advanced care providers, patient care technicians, etc. 60% of responders preferred the lateral hip on themselves. 50% preferred the lateral hip on their partners. 23% preferred the buttock on their partners. 20% had no preference of donor site on their partners.ConclusionsA decision tree model can be made to help with consultation on donor site preference to enhance the surgical consent process between patient and surgeon.Applicability of Research to PracticeDirectly applicable
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.363
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 325 Inpatient Rehabilitation Program Specializing in Burn Rehabilitation:
           One Center’s Outcomes
    • Authors: Fletchall S; Clark M, Geib T, et al.
      Abstract: IntroductionSince 2016 designated beds within the hospital’s current inpatient rehabilitation facility (IRF) has been identified for patients with the diagnosis of burn. Following admission to the IRF, the patient with the burn diagnosis, experiences a continuum of burn care as daily treatment is provided by the burn physicians, burn mid-level extenders, and burn therapists. The outcomes from this specialized burn program in the IRF are compared with national and regional data. The outcome comparison assisted in identifying areas for improvement and areas of strength.MethodsERehab was used to compare of the IRF’s burn outcomes to national and regional data. ERehab is fee based online system from the American Medical Rehabilitation Providers Association. The online system can facilitate the IRF to comply with CMS regulations and allows a simultaneous comparison of IRF data with national and regional areas. The data of eRehab is obtained from a chart review performed while the patient is in acute care and after IRF admission from the Functional Independence Measure aka FIM. The FIM, used by IRF therapist and nurse, score the patient’s level of function in physical, psychological and social function. The FIM is scored upon IRF admission and discharge. The data reflects the timeframe of
      DOI to IRF admission, age, gender, length of stay, FIM score at admission and discharge and discharge placement.ResultsComparison of the data of burn diagnosis in eRehab shows an earlier admit into the burn IRF from 4.51 to 16.37 days sooner than regional or national areas. However, during the first year, 2016, the LOS was 7 days greater than the national data. By 2018, the LOS was similar to the regional and national areas with a variance of 0.3 to 1.64 days, respectively. The patients are admitted to the specialized burn IRF program with higher FIM scores and are discharged with higher FIM scores as compared to the national and regional data. The comparison of data shows the specialized burn IRF program has a greater number of patients discharged home, fewer transferred to SNF or discharged home with home health.ConclusionsSpecialized burn IRF program, with majority of the acute care burn team providing daily services can result in higher FIM discharge scores and higher potential of being discharged home.Applicability of Research to PracticeData indicates transfers from the burn center to the specialized burn IRF program is quicker than national/regional areas, which allows acute care burn beds to be used appropriately. However, a multi-center study focused on burn diagnosis in IRF would provide greater information to reflect the long term effects related to burn scar contractures, return to pre-burn activities and IADL’s.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 109 Evaluation of Autologous Skin Cell Suspension for Healing of Burn
           Injuries of the Hand
    • Authors: Molnar J; Holmes J, Carter J, et al.
      Abstract: IntroductionProper treatment of hand burns is critical, as the function and aesthetic appearance play an important role in the patient’s ability to work and return to normal life. Hand burns are often treated with non-meshed autografts to achieve the best results possible. However, in larger TBSA injuries, there are limitations with availability of donor skin, and often wide mesh grafting is required to achieve definitive closure. In a recent pivotal randomized controlled trial (RCT), it was demonstrated that autologous skin cell suspension (ASCS) in combination with widely meshed split-thickness skin graft (STSG) achieved comparable healing and long-term outcomes to a less widely meshed STSG, however this study excluded the evaluation of hands and the safety and effectiveness has not been established. Through continued access of the pivotal RCT as well as through compassionate use of ASCS, hand burns were treated with ASCS across 5 US Burn Centers. The purpose of this study is to present the clinical results obtained using this treatment strategy.MethodsPatients were included in the study as part of IDE 13053 and IDE 15945 and had mixed-depth or full-thickness burns to the hands treated with ASCS in combination with meshed STSG. Adult and pediatric patients were included in the series and consented for education and research photographs in compliance with institutional standard of care and protocol requirements. Outcomes analysis included percent re-epithelialization, subjective cosmetic parameters, and adverse events including surgical intervention for graft failure or contracture release.ResultsThirty patients were treated for hand burn injuries, totaling 50 hands treated. The average age was 36.7±21.0 and average TBSA was 47.8±23.7%. The majority of hands were treated with ASCS+3:1 meshed graft (60%). For evaluable wounds, 7 days following treatment, 51% (19/37) had ≥95% re-epithelialization and at 4 weeks 86% (38/44) had ≥95% re-epithelialization. At one year, the majority of all evaluable hands were matched or mildly matched in color (23/29), pigment (21/29) and texture (15/29) when compared to uninjured surrounding skin. Surgical intervention was required for regrafting (14%) and contracture release (16%) of hands treated.ConclusionsNon-cultured, ASCS can be used in the treatment of mixed depth hand burns to achieve definitive closure of hand burns.Applicability of Research to PracticeASCS is a novel autograft-sparing technology that should be considered for use as part of a surgeon’s treatment algorithm for treating highly visible and functional areas.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.110
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 425 Assessing Demographics in Patients Screening Positive for
           Post-Traumatic Stress Disorder following Burn Injury
    • Authors: Simmons E; Galicia K, Kishawi D, et al.
      Abstract: IntroductionStudies have demonstrated that burn patients suffer from post-traumatic stress disorder (PTSD). The development of PTSD after burn injury has been found to be related to predictive factors such as TBSA, length of hospital stay, and female sex. Several studies have investigated the prevalence of PTSD in the adult burn population with regards to patient demographics. To date, it appears as though demographic studies have only considered age, race, and sex as variables predictive of PTSD development. As researched, the mechanism of burn injury seems to be an important demographic factor as well.MethodsThis study was a retrospective chart review of patients >18 years of age who screened positive for PTSD in an outpatient burn clinic between February 2017 to August 2018. As part of this chart review, mechanism of burn injury, percent total body surface area (TBSA) involved, length of hospital stay, and need for surgery was determined for each patient. Demographic data, including sex, age, race, zipcode, insurance status, and employment status was also collected. Descriptive statistics were used for baseline demographics.ResultsData from 408 positive PTSD screens was analyzed, with 213 unique patients identified. Of the patients, 43% were female; average age was 41.6 years old (range from 18-92); TBSA ranged from 0.10%-47.15%; mechanism of injury included 43.7% from flame injury, 33.3% from a scald injury, 10.3% from contact injury, and 6.3% incurred burn injuries from other mechanisms. Race demographics included 47.4% White, 24.7% Black/African American, 13.7% Hispanic, 0.9% Asian, 11.8% other, 0.4% multiracial, and 0.9% unindicated; LOS ranged from 0 days to 74 days, with an average of 5.4 days; 23.1% of patients had an OR visit during their stay after their burn injury; 82.9% of patients were insured (19.2% of which were Workman’s Compensation); 43.8% were employed, 33.8% were unemployed, 5.23% were retired, and 17.1% did not indicate their employment statusConclusionsWhen comparing demographics of burn patients, there were no clear determining factors that were predictive of those who screened positive for PTSD. There was a large percentage of insured patients who were under Workmen’s Compensation. Also, there was a high variation of TBSA and less than 25% of those who screened positive for PTSD went to the OR during admission.Applicability of Research to PracticeContinued screening of burn patients regardless of demographic factors in order to ensure identification of patients with psychological distress to and provision of targeted resources.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.322
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 278 A Comprehensive Legislative Framework to Address Chemical Assault
    • Authors: Stewart B; Kazerooni Y, Mishra B, et al.
      Abstract: IntroductionThe incidence of chemical assault is increasing globally and there are no evidence-based legislative approaches that target chemical assaults. To fill this gap, we aimed to develop a comprehensive legislative framework for advocacy groups and governments that might inform ways to control chemical assault.MethodsTerms related to chemical assault were used to systematically search the academic, lay, and legal literatures (i.e., PubMed, World Health Organization Catalog, LexisNexis Academic, LexisNexis Advance, Google). Data regarding relevant legislation and the relative impact on chemical assaults were extracted. Chemical assault was defined as the use of acid or another caustic or corrosive substance or vitriol by one person against another with the intent to injure or disfigure. Reports that described the use of chemical weapons in warfare were excluded. A secondary search of national legislations of countries with report(s) of chemical assault was done to construct a comprehensive legal framework based on existing laws and regulations using content analysis.ResultsAfter duplicates were removed, 2,366 records were screened for relevance. Most records (1,897 records) pertained to medical, surgical and psychosocial care of chemical injuries and were excluded. Of the remaining 470 reports, 384 met criteria for analysis. Chemical assaults were reported from 53 countries. From the laws and regulations of these countries, a framework consisting of 5 legislative priorities was developed: i) apply a public health approach; ii) adopt legal definitions specific to chemical assault; iii) control chemical supply, sales, and procurement; iv) facilitate justice; and v) support survivors. No country has implemented all of these legislative priorities.ConclusionsThe comprehensive legislative framework strategically incorporates existing chemical assault control efforts. Comparative policy analysis and assessments of the impacts of new and/or additional legislative efforts may further inform strategies to prevent, prosecute, and mitigate the impact of chemical assaults.Applicability of Research to PracticeAdvocacy groups and governments might consider implementation and enforcement of the legislative framework to control the growing epidemic of chemical assault.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.196
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 227 Reducing the Incidence of Hospital Acquired Pressure Ulcers in the
           Burn Unit
    • Authors: Fitzgerald N; Sood R.
      Abstract: IntroductionHospital Acquired Pressure Ulcers are a concern for all inpatients that lack the ability to mobilize themselves, have incontinence issues or open wounds, and/or are nutritionally challenged or impaired. All of these contributing factors to HAPU are found in our burn patients. In our burn center, the HAPU rate was elevated in 2016 with a 2.1% rate of HAPU incidence (n=7 incidences of HAPU). I the first quarter of 2017 we experienced three additional incidences of HAPU. The performance improvement team identified an opportunity for improvement and an educational program was put into place to examine patient care staffs’ knowledge on HAPU prevention and intervention in an effort to decrease HAPU in our unit.MethodsThe education event was designed as a HAPU Prevention fair that included posters and hands on stations related to patient care and HAPU prevention. There was information provided on z-flow positioners, the SOS policy, an algorithm on when to utilize various bed surfaces, information on each of the available beds within the burn unit, as well as information on how to prevent friction with patient movements. Attendance by all staff in the Burn Center, inpatient, outpatient and operating room, was mandatory. A pre and post-test was utilized to determine the effectiveness of education.ResultsPre-test scores for the HAPU Prevention fair had an average of 47%. Post-test scores for the HAPU Prevention fair had an average of 89%. The post-test was given again in March of 2018 to all staff that had taken it previously and the average score remained at 89%. This prevention education is included in quarterly education for all Burn Center staff. Since the HAPU Prevention fair we have had 1 HAPU reported in a year since the HAPU Prevention fair.ConclusionsTo make HAPU a never event continued efforts will need to be made to provide education to staff and find additional mechanisms to drive down rates. Continued hands on education with relation to the tools already available is just one way that rates can be impacted based on the evaluation of staff knowledge and HAPU rates within our unit.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.155
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 64 The Effects of a Trauma Recovery Program for Burn Patients on the Acute
           Phase
    • Authors: Hwang S; Lim J.
      Abstract: IntroductionReports on psychosocial interventions document the efficacy of group interventions to reduce psychological distress and post-traumatic stress disorder(PTSD) symptoms among burn patients on the acute phase. The less favorable outcomes of burn patients and paucity of literature documenting culturally responsive intervention studies for Korean patients add to the urgency of this research. This study investigates the effects of a trauma recovery program with Korean burn patients on the acute phase.MethodsA total of 42 participants were recruited from a specialized burn center in a hospital located in Korea. Eligible participants included individuals 18 years of age and older, within 6 months after burn injury. Participants completed a baseline and follow-up measure that assessed perceived stress level, psychological distress(BSI-18), PTSD, pain. Based on their reported level of motivation and PHQ-9 score, participants were assigned to the experimental or control group. Those in the experimental group(n=25) participated in the “SPA” program which is comprised of 4 topics from scent, music, meditation, and pain for increasing physical and psychological stability for burn patients. The four sessions lasted approximately 1 hour each for 2 weeks.ResultsFindings have revealed statistically significant differences in both the experimental and control groups in perceived stress(p<.05) and pain (p<.05) at baseline. The control group reported higher stress and pain than the experimental group during baseline. A repeated measures analysis revealed significant differences for perceived stress(p<.05), PTSD(p<.05), psychological distress(p<.05), and pain(p<.05) by study condition. That is, PTSD and psychological distress scores improved from baseline to follow-up for the experimental group only. The level of psychological distress of the experimental group reduced over time, while that of the control group increased. More specifically, ‘hyperarousal’ and ‘emotional desensitization’ which are two domains of the PTSD symptoms revealed significant improvement for the experimental group only.ConclusionsFindings on the effects of the “SPA” reveal significant improvements in perceived stress, psychological distress, PTSD symptoms, and pain. Further, result indicate that after intervention the control groups report less favorable psychological distress and PTSD scores specifically than the experimental group.Applicability of Research to PracticeThe “SPA” interventions if implemented early may help alleviate and prevent some negative outcomes among burn patients at greatest risk for poor outcomes. Findings may enlighten clinicians and researchers on practical models and strategies to reduce psychological distress and PTSD symptoms and preserve emotional stability.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.067
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 513 A Survey of Bacterial Microbiome Dysbiosis in Burn ICU Patients
    • Authors: Lima K; Bullock H, Davis R, et al.
      Abstract: IntroductionWith the advancement of nucleic acid sequencing technologies and bioinformatic power, a boom of the “-omic” era has revolutionized how we understand host microbiome interactions. Dysbiosis of the skin and gut microbiota have correlated with many immune disorders and chronic diseases. These associations are often not universal, making it critical for unique populations to be studied individually. Numerous aspects of the response to burn injury and resulting care can influence normal commensal bacteria on the skin and gut.MethodsHealthy volunteers were swabbed in two locations on each forearm for validation of non-invasive skin bacterial sampling techniques, with a subset utilized for bacterial population comparison with burn patient samples. Patients with >10% total body surface area (TBSA) burns were sampled using sterile swabs on the burn wound and a corresponding spared site of the skin, as well as one peri-anal and rectal swab. These four locations were sampled on days 0, 3, 7, 14, and 21 of the patient’s ICU stay or up to discharge. Metadata collected includes demographics, medications, nutrition plan, and progress notes. A next generation 16S amplicon sequencing protocol was utilized in conjunction with bioinformatics performed using Nephele under the QIIME pipeline.ResultsTwenty healthy volunteers were recruited for method validation. Four male burn patients were recruited with a mean age of 42 (SD=13.4) years and mean total body surface area (TBSA) burn of 24.1% (SD=8.1). Comparison of healthy volunteer skin swabs (n=18) to burn wound swabs (n=12) found a significant reduction in percent relative abundance of the phylum Actinobacteria (p<0.001) and increase in the order Bacillales (p<0.05), composed of primarily Staphylococcus. Varying abundance of non-culturable bacteria were sequenced. The Shannon Diversity Index was most variable among wound swabs (n=12) (mean [SD]: 4.09 [2.15]). No significant difference between pooled taxa percent abundance for rectal and peri-anal sampling (p=0.297) was observed.ConclusionsProportions of bacterial phyla that are “normal” colonizers of the skin, such as Actinobacteria and Firmicutes, are perturbed on the burn wound and spared skin sites sampled from the four subjects. The clinical significance of non-culturable bacteria remains unknown. These findings suggest that bacterial dysbiosis occurs on the burn wound following injury and remains perturbed during routine care. Rectal and peri-anal swabs did not significantly differ in taxa relative abundance, indicating that less invasive sampling could be used.Applicability of Research to PracticeProfiling microbial populations immediately post burn and throughout care is the first step in elucidating mechanisms by which bacterial dysbiosis occurs and if this perturbation impacts clinical outcomes.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.403
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 108 Therapeutic Drug Monitoring (TDM) Revealed Alarming Rate of
           Subtherapeutic Drug Concentration in Burn Patients Treated with
           Beta-Lactam (BL) Antimicrobials
    • Authors: Burch G; Carson J, Cherabuddi K, et al.
      Abstract: IntroductionWith sepsis being the leading cause of mortality in burn patients, effective antimicrobial therapy is essential to burn care. Complex physiologic and metabolic changes associated with thermal injury markedly complicate pharmacokinetics in these patients, making it difficult to predict an individual’s response to a particular dose of antibiotics. We hypothesized that the standard dosing schemes would fail to yield therapeutic concentrations of BL’s in a significant portion of burn patients.MethodsWe performed a retrospective analysis of adult burn patients receiving beta-lactam TDM following receipt of ≥ 48 hours of cefepime, piperacillin-tazobactam, or meropenem from March 1, 2016 to June 30, 2017. Peak (1-hour after infusion) and trough (30 minutes prior to next dose) concentrations were obtained at steady state. TDM was initiated at the discretion of the burn pharmacist and physician. The primary endpoint was the percentage of the study population who achieved serum concentration 4 times above the minimum inhibitory concentration (MIC). Secondary endpoints included clinical cure, microbiologic eradication, resistance selectionResultsTwenty patients (16 male, 4 female) with median TBSA of 22% and age of 43 years were included in the analysis. Measured trough concentrations varied substantially for all three beta-lactams: cefepime (8.1–65.0 mcg/mL, median = 15.4 mcg/mL), piperacillin-tazobactam (5.9–74.6 mcg/mL, median = 16.4), and meropenem (2.7 - 28.3 mcg/mL, median = 25.0). Only 40% of patients achieved a therapeutic trough concentration, defined as ≥4xMIC, with standard dosing regimens. Clinical cure and microbiologic eradication was observed in 60% and 68% of patients, respectively. However, 27% of patients became culture-positive for an organism resistant to the primary antibiotic.ConclusionsIn this population, therapeutic drug monitoring identified significant variation in antibiotic exposure in burn patients treated with beta-lactam antibiotics. Standard beta-lactam dosing strategies yielded subtherapeutic serum concentrations in a majority of patients studied. This study indicates that selective TDM of beta-lactam can allow the clinician to identify and correct under-dosing of antimicrobiotics in burn patients. Further research is needed to determine whether a broader application of TDM could improve antimicrobial therapy in burn patients.Applicability of Research to PracticeAn immediate application to optimization and personalization of antibiotic therapy for infected burn patients.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.109
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 324 Head-Neck Helmet Cast for Neck Burns: A Case Report
    • Authors: Sharma A; Sterling D, Bhavsar D, et al.
      Abstract: IntroductionFull thickness neck burns often require skin grafting to prevent scar contractures which can result in functional deficits, self-image problems and affect social relations. Proper positioning of neck immediately after grafting is important for graft adherence. This can be challenging despite the availability of multiple positioning devices. Prefabricated hard collars, thermoplastic collars can be uncomfortable and patient being able to remove them results in noncompliance. After trying a few conventional neck positioning/and or pressure techniques we had success with an innovative head-neck synthetic cast.MethodsThis is a report of 30-year-old-male who sustained 2% total body surface area full thickness burn to the right posterolateral neck. On admission tangential excision was performed with wound vacuum-assisted closure (VAC) device placement. However, patient picked at the wound VAC dressing and removed it. Wound VAC was replaced and a soft collar was applied. Patient then received a split thickness skin graft (STSG) with a bolster covering it. It was noted that patient was separating bolster from skin and was picking at STSG. Anterior and posterior thermoplastic collars were fabricated to prevent patient from picking at graft. Patient was non-complaint and had a complete graft loss. Patient returned to operating room 5 days after initial STSG and received another STSG with wound VAC placement. A synthetic head-neck cast was molded in the operating room after re-grafting to prevent patient from picking at graft and improve compliance. With this cast patient was unable to reach the graft site. On post-operative day 5, graft was assessed and was found to be mostly adherent. Head-neck cast was converted into a univalve removable cast, passive range of motion (ROM) was initiated and was noted to be within normal limits. On post-operative day 8 cast was removed as graft was adherent, and a soft collar was applied. Active ROM exercises were initiated.ResultsWith use of head-neck cast we were able to surgically treat full thickness neck burn wound, prevent severe scar contractures and reduced risk of infection. Patient had good graft adherence as patient was unable to access the graft. There was improved compliance and comfort. Active ROM of neck at discharge was within normal limits.ConclusionsThe head-neck cast has several benefits including being inexpensive, time effective, light weight. It allows good anatomical molding and can be converted into a removable/univalve cast for graft inspection. This head-neck cast can serve as a good option for improved compliance in pediatric and non-compliant adult patients with neck burns.Applicability of Research to PracticeThis case report depicts the importance of head neck helmet cast to improve adherence of graft.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.237
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 24 Burn Prevention Engagement: Little Ambassadors of Health
    • Authors: Korber K; Possenti P.
      Abstract: IntroductionThere is historical precedence for using storybooks and characters as engagement resources and reinforcement tools for effective patient education.(1,2)MethodsWe set out to design, develop, publish, and disseminate a novel approach to the expansion of *ambassadors-of-health* among 3–6 year-old readers; within a burn prevention environment. A burn prevention activity book was created and presented to a cohort of 1,089 young readers already familiar with the embedded characters, from other published stories. In addition, new burn care audiences were given the same interactive learning opportunity; through generous nonprofit grant awards.ResultsBaseline and acquired knowledge was assessed in a variety of early childhood development environments. And long-term knowledge retention assessment was revisited at 60- and 90-days after the initial exercise event.ConclusionsGreater than 90% of baseline knowledge parameters were reported improved using the activity tool, and decay of this knowledge was only 3% after 3 months. This pilot reaffirms the notion that, when engaged properly, the littlest of patients can serve as ambassadors of healthy behavior for themselves, their peers, their families, and their communities.Applicability of Research to PracticeThe fundamental public health challenges of preventing burn injuries can be efficiently addressed when the resource/tool resonates with the target audience in a cost-effective way. A low tech storybook is not only a malleable tool, but, the combination of reading skills with health promotion messages can be useful and have sustainable impact.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.028
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 468 Surgical Fires and Burns: A 5-year Analysis of Medico-legal Cases
    • Authors: Calder L; Héroux D, Bernard C, et al.
      Abstract: IntroductionSurgical fires and unintended intra-operative burns are “never events”, yet they continue to occur. Medico-legal data provide unique information on the nature of surgical fires and burns and their contributing factors, which can inform strategies for burn prevention.MethodsWe extracted five years (2012-2016) of data on closed medico-legal cases involving surgical fires and burns from a database which provides medico-legal support to over 95% of Canadian physicians. We performed a retrospective descriptive analysis of the contributing factors using an in-house coding system and independent manual review of the cases by two registered nurses.ResultsFifty-three cases were identified. Twenty-six cases originated from thermal sources (49.1%), 16 from fires (30.2%), 5 from chemical sources (9.4%), and 6 from undetermined sources (11.3%). Burns affected <10% total body surface area (TBSA) in 62.3% of cases, 10-19% in 3.8%, or unspecified TBSA in 34.0%. Approximately 90% involved the head/neck (49.1%) or trunk (41.5%). Common contributing factors were improper use or malfunction of devices such as cautery resulting in thermal burns, oxygen concentration above the lowest level during electrocautery causing fire, and incorrect application of antiseptic agents during skin preparation leading to chemical burns. Non-technical factors also contributed, such as failure of surgical teams to communicate critical information intra-operatively.ConclusionsThese results demonstrate that it may be beneficial to focus on strategies to improve situational awareness, including team communication, and adherence to surgical safety protocols and policies in order to mitigate surgical burns or fires.Applicability of Research to PracticeWhile infrequent, these events provide opportunities to improve surgical safety. Effective team communication and system strategies to manage the fire triangle (ignition, oxygen, fuel) may help prevent these “never events”.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.362
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 371 Retrospective Analysis of Ocular Involvement and Outcomes following a
           Novel Approach to Application of Amniotic Membrane Graft in the Management
           of Stevens - Johnson Syndrome and Toxic Epidermal Necrolysis at a Level
           One Burn Center
    • Authors: Reed D; Mehta A, Giles G, et al.
      Abstract: IntroductionStevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TENS) is a significant cause of ocular morbidity and is associated with a spectrum of ocular surface injury, presenting unique challenges concerning preservation of visual function for the burn surgeon. This study aims to quantify the rates and describe the extent of ocular injury and visual outcomes following aggressive ocular surface treatment in patients with SJS/TENS. Additionally, a novel approach to amniotic membrane grafting to the ocular surface in the management of SJS/TENS is described.MethodsThis study is a retrospective analysis of 38 cases of SJS/TENS diagnosed by clinical and dermatopathologic evaluation at, a level one burn center. The rates and extent of ocular injury were assessed. Comparisons were made regarding extent of injury, treatment, and visual outcomes following ocular surface therapy.ResultsTwenty-two (58%) cases had ocular involvement. Of those with ocular involvement, four cases (18%) had trichiasis. Additionally, two cases of stromal haze were identified and one case had symblepharon on presentation. All cases with ocular involvement received a combination of anti-inflammatory, antibiotic, and/or lubricating ocular drops. Eight (36%) cases required placement of Prokera © amniotic membrane rings. Four (18%) received a 5x10cm amniotic membrane graft to the entire ocular surface and eyelid margins with overlying symblepharon ring via application of cyanoacrylate glue to the external lids. The ocular surface integrity was maintained in all cases following application of amniotic membrane.ConclusionsOcular injury is common in SJS/TENS and requires urgent ophthalmologic evaluation. As subjective patient data is often less readily available, a high index of suspicion and thorough investigation is warranted and aggressive ocular surface therapy is required in caring for these patients to preserve visual function.Applicability of Research to PracticeApplication of amniotic membrane graft to the entire ocular surface including the eyelid margins via cyanoacrylate glue application with the addition of an overlying symblepharon ring is an effective and efficient option for the maintenance of ocular surface integrity and ultimately visual preservation in moderate to severe SJS/TENS.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.279
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 424 Safety of Outpatient Management of Pediatric Hand Burns in an Urban
           Burn Center
    • Authors: Lee M; Young B, Ladhani H, et al.
      Abstract: IntroductionThe inquisitive nature of pediatric patients places them at risk for burn injuries of the hand. While there is literature to guide management of these burns, studies of outpatient management, specifically rates of surgical intervention and infection are lacking. Current studies in the literature estimate up to 20% of all pediatric hand burns are admitted. The goal of this study was to profile pediatric hand burns presenting to our clinic and determine rates of admission, surgical intervention, and adverse outcomes. We hypothesized that outpatient management is safe and effective, with low rates of unplanned admission, infection, and surgical intervention.MethodsWe performed a single-center retrospective analysis of outpatient records at an ABA-verified burn center serving adult and pediatric populations. We identified pediatric patients under 18 years of age with a burn injury to the hand or wrists that were seen in the outpatient clinic from 1/2014 - 11/2016. Patients with superficial, first-degree burns, or minimal burn injury (TBSA </=.1%) were excluded. Descriptive analysis was performed to identify patient demographics, injury characteristics, treatment patterns, and outcomes.ResultsA total of 198 patients met inclusion and exclusion criteria. Median age was 2 years (IQR 1-9). Median TBSA was 0.5%; 149 patients (75%) had burns isolated to the hand with 5 patients (3%) having full thickness burns. Contact burn was the most common etiology (49%) followed by scald burn (37%). 114 patients (58%) were seen during regular clinic hours. 175 patients (88%) were initially prescribed a topical antibiotic ointment with a petrolatum-based gauze. 51 patients (33%) were prescribed compression therapy. Median number of total visits were 2 (IQR 2-3) and median length of followup was 11 days. 11 patients (6%) were admitted at initial visit and 9 patients (5%) required split-thickness skin grafting. One patient was admitted unexpectedly and one patient developed a wound infection.ConclusionsThe incidence of outpatient pediatric patients with a thermal injury to the hand requiring admission or surgical intervention is low. Unexpected admissions and complications including wound infection were rare in patients with both partial and full thickness burn.Applicability of Research to PracticeThis finding suggests that pediatric patients with thermal injuries to the hand can be safely managed in an outpatient setting with appropriate care.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.321
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 226 Book Club Live! Utilizing a Mixed Model of Learning in the Burn Center
    • Authors: Stephens L; Correa P.
      Abstract: IntroductionThe nursing learning environment is challenging due to many factors such as staffing shortages, difficulty carving out dedicated learning time and skill mix of Registered Nurses. To attempt to bridge the generational gap as well as teach in a new and exciting way, the Clinical Nurse Educator created a program that brought a book club to life. Each week a chapter of the book was read by the participants and a content expert spoke. The Burn Center is an 8 bed ICU/16 bed Floor ABA verified unit in an Academic Medical Center in the Southeastern United States. The Burn Center sees greater than 400 adult and pediatric burn patients per year The unit employs 42 Registered Nurses (RN). The average tenure of RN’s is 4.59 years, with 21 having less than 2 years of experience. The generational background is 58.54% Millennials, 26.83% Generation Xers, and 14.63% Baby Boomers.MethodsThe initial group of 10 RN’s were provided the book Burn Unit by Barbara Ravage. One chapter was read each week. The goal of the teaching was to join personal stories, current practices, and cross-generational learning into a relevant teaching model that would have a lasting impact. Each chapter contained a speaker or tour as well as a focused learning guide. The speakers included Attending Physicians, Residents, Advanced Practice Providers, Nurse Executives, Psychiatrist and tours of the Level I Trauma Center Emergency Department and the onsite Hyperbaric Chamber. A pre and post survey was given to all participants. Every chapter has shown at least one improvement in the knowledge of the participants as well as a satisfaction with the learning method.ResultsOver the ten-week program, the total participation was 142 employees with 54 unique attendees. The 60% increase in attendance spoke to the engagement and learning of the staff as well as the positive interest in this mixed model of learning. Overall, 99% of the attendees agreed or strongly agreed that the book club method would prove helpful for future learning offerings.ConclusionsUtilizing mixed methods of learning has positive potential for effective learning delivery across multiple generations and disciplines in the acute care setting of an academic medical center. Expansion of this learning model should be tested in other specialties to determine its effectiveness on retention of knowledge, engagement, and expansion to other learning environments such as nursing grand rounds and new graduate orientations.Applicability of Research to PracticeThe work completed on the development of the book club crossed generational and multi-disciplinary barriers to open an opportunity to learn in a new and exciting way. This program has been duplicated in multiple practice areas with good results and an IRB approved study has spun off of the book club model.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.154
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 63 Characterizing Fentanyl Variability using Population Pharmacokinetics
           in Pediatric Burn Patients
    • Authors: Grimsrud K; Felth L, Lima K, et al.
      Abstract: IntroductionPain management is critical for burn care with opioids serving as first line analgesics. Opioid dosing remains challenging in burn patients, especially in pediatrics, due to the immense interpatient variability in efficacy. Burn patients experience greater variability due to the impact of burn related comorbidities impacting opioid metabolism. This is exacerbated in children where developmental and physiological differences nullify dosing extrapolated from adult-data. A better understanding of the range of variability in the pharmacokinetics (PK) and pharmacodynamics (PD) of opioids in pediatric burn patients is warranted to optimize dosing. The goal of the present study is to characterize the variability in fentanyl PK in pediatric burn patients and identify significant covariates.MethodsPatients with ≥ 10% total body surface area (TBSA) requiring intravenous fentanyl during routine wound care were enrolled in the study. Patient demographics, fentanyl dosing and other clinical data were recorded. Serial blood samples were collected at approximately 5, 30, 60, 120, and 240 minutes post fentanyl administration. Serum fentanyl concentrations were quantified using tandem liquid chromatography mass spectrometry (LC-MS/MS). Population PK analysis with Monolix software was used to estimate clearance (CL) and volume of distribution (Vd) parameters.ResultsFourteen patients, 1.2 to 17 yrs old, with TBSA ranging from 10 to 50.5% were enrolled. A two-compartment PK model with weight as a covariate best described the fentanyl profiles for the overall population. The population CL and intercompartmental clearance (Q) were 7.19 and 2.16 L/hr, respectively, and the Vd1 and Vd2 were 4.01 and 25.1 L, respectively. Individual patient parameter estimates had extensive variability with some patient data poorly fitting the model. There was no significant correlation between CL and TBSA identified in these patients.ConclusionsThis study confirmed the high variability associated with fentanyl PK in pediatric burn patients. While some of these pediatric patients CL values were similar to the CL of non-burned pediatric patients reported literature, others were more in the range of CL reported for critically ill and elderly adults. Further research is needed with a larger number of patients to extensively investigate the impact of burns, genetic polymorphisms and other factors on opioid PK/PD and patient outcomes.Applicability of Research to PracticeThere is a vital need to better understand the variability in opioid PK to improve dosing regimens. Data obtained from this study informs clinicians that individualized opioid dosing in patients is warranted and further research is needed to understand the factors associated with opioid PK and PD variability.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.066
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 23 Burns in Octogenarians: 80 is the New 60
    • Authors: Grigorian A; Joe V, Chin T, et al.
      Abstract: IntroductionGeriatric trauma patients (age≥65 years) with burn injuries have a 5x higher mortality rate compared to younger adults. Although the LD50 for children and younger adults has improved significantly over the past decade, it remains at 35% total-body surface area (TBSA) for geriatric patients. Due to an aging population, the proportion of octogenarians (80–89 years) suffering burns are increasing. An analysis from over a decade ago using the National Burn Repository demonstrated a linear increase in mortality for patients older than 65-years. We hypothesized that octogenarians with burn injuries would have a higher rate of in-hospital complications as well as mortality, compared to patients aged 65–79 years.MethodsThe Trauma Quality Improvement Program (2010–2016) was queried for patients with any burn injuries. Two groups were compared: age 65–79 vs 80–89. A multivariable logistic regression model was used to determine risk for mortality.ResultsFrom 282 patients, 209 (74.1%) were aged 65–79 and 73 (25.9%) were 80–89. Both groups had a similar median injury severity score (ISS) (p=0.81), TBSA (p=0.30) and rate of comorbidities except for higher rate of smoking (12.9% vs. 4.1%, p=0.04) and lower rate of hypertension (52.2% vs. 65.8%, p=0.04) in the age 65–79 group. Octogenarians had a similar rate of complications (acute kidney injury, acute respiratory distress syndrome, deep vein thrombosis, pneumonia) (p>0.05) as well as mortality (15.1% vs. 10.5%, p=0.88), compared to those aged 65–79. On multivariable logistic regression, octogenarians were not associated with increased risk of mortality (p=0.67).ConclusionsCompared to patients aged 65–79 with burn injuries, octogenarians have a similar rate of complications and risk of mortality. This differs from a previous national database analysis.Applicability of Research to PracticeOctogenarians are making up a larger proportion of patients admitted for burn injuries than ever before. Among patients ≥65 years, age in of itself is not a significant predictor of mortality. Future research on alternative methods to prognosticate mortality in elderly burn patients, such as development of a burn-related frailty index appears warranted.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.027
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 323 Considerations for the Development of an App to Measure Burn Patient
           Outcomes: An International IT Perspective
    • Authors: Klotz T; Kurmis R.
      Abstract: IntroductionTechnology is increasingly utilised to improve and streamline patient care. With the rapid adoption of electronic medical record systems and availability of hand held smart devices, the use of applications (Apps) to assist decision making is increasing. In burn care Apps are used to assist with percentage total body surface area burned and required fluid resuscitation calculations. In our endeavours to digitise a manual scar assessment tool previously developed at our centre, we uncovered many important considerations unique to this rapidly evolving space, of which we aim to present an overview.MethodsA needs assessment was conducted prior to project initiation. The optimal digital platform for the App was determined, based on accessibility, ongoing App maintenance requirements, and their subsequent costs. A quote for development was obtained from a digital designer experienced in health Apps. Project funding was sourced following a grant application. Local ethics and research governance consent was obtained for the reliability testing on patients, along with the use of de-identified and consented clinical photographs within the App itself. Following project initiation, state information computer and technology (ICT) security requirements changed along with the implementation of the European General Data Protection Regulation (GDPR), leading to changes in the App design relating to patient data input and output capabilities. For launching on the App Store within the US the Health Insurance Portability and Accountability Act (HIPPA) requirements were also considered. App disclaimers required review by health department legal experts prior to inclusion. Inter-rater reliability testing was conducted on a predetermined number of burn scars based on calculations provided by a health statistician.ResultsAn App to assist the assessment of scar outcome measures was developed, that complies with local and international regulations pertaining to safety of sensitive individual data. The App assists clinicians and researchers with assessment of burn scars, in a visual and practical way, with reporting output suitable for inclusion in paper or electronic medical record formats.ConclusionsSmart devices are increasingly being used to support clinical decision making and are a practical asset to utilise. Due to rapidly changing requirements in this space, and various international regulations governing the collection, use and storage of patient information, a considered approach is needed prior to development of Apps or use in burn injury careApplicability of Research to PracticeLocal ICT security, GDPR and HIPPA requirements should be considered when implementing App based assessment tools into clinical practice.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.236
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 466 Development of an Acute Kidney Injury Evaluation Tool
    • Authors: Libraro K; Parizh D, Lorico J, et al.
      Abstract: IntroductionAcute Kidney Injury (AKI) diagnosis is greatly associated with increased mortality, length of stay, and hospital costs. Multiple diagnoses of AKI as a complication motivated the burn quality team to examine the contributory factors and establish program improvement metrics for AKI prevention, diagnosis, and treatment. Through Root Causes Analysis outcomes, emphasis on BQIP criteria, and awareness of nephrotoxic agents, the quality team created an ‘Acute Kidney Injury Tool’. This tool has provided efficient and measurable data to assess and quantify the contributory factors of the AKI diagnosis.MethodsA review of 2012, the Kidney Disease: Improving Global Outcome (KDIGO) Foundation definition of Acute Kidney Injuries, the BQIP criteria for diagnosing AKI as a complication, and retrospective patient chart reviews were performed.ResultsInitial results included the development and utilization of the AKI tool as a retrospective means of quality review. These reviews and initial findings furthered the quality opportunities of this initiative. Data suggested that overall burn shock resuscitation was somewhat inconsistent leading to the development of a 24 and 48-hour fluid resuscitation document. This document assisted in more real-time assessment of actual verse goal fluid intake and urine output (Figure 1).ConclusionsCombining these inclusions with information obtained from appropriate burn shock resuscitation, initiation of albumin, cyano-kit administration and other nephrotoxic agents helped to establish a questionnaire to analyze both patient specific and disease specific relations to large open surface area and Acute Kidney Injuries. The Burn Center hopes that statically significant information obtained from these questionnaires will aide in the prevention and decrease of Acute Kidney Injury diagnoses through early recognition of causative and correlative factors.Applicability of Research to PracticeProvision of a tool to characterize AKI in the burn patient.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.361
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 107 Post-Operative Wound Management Following the Use of an Autologous
           Cell Harvesting Device in the Treatment of Patients with Life-Threatening
           Injuries: A Single Center’s Experience
    • Authors: Craig C; Williams J, Barone C, et al.
      Abstract: IntroductionThe use of autologous skin cell suspension (ASCS) allows for the preparation and spray application of a non-cultured skin cell suspension in lieu of, or to augment, standard meshed split-thickness skin grafts (STSG). This technique promotes epidermal regeneration and rapid wound healing, while reducing the amount of skin harvested to cover large burns (up to 80:1 expansion). Previously, the use of ASCS in the US was limited to investigational use; however, a device is now FDA-approved and will likely be used to treat burns. Given the unique nature of this grafting technique, it is valuable to disseminate our experiences with ASCS post-operative wound management gained during participation in 2 FDA trials.MethodsPatients who presented with a life-threatening burn injury and lacked adequate STSG donor sites were enrolled into a prospective, uncontrolled, observational, compassionate-use study evaluating the use of ASCS for burn treatment. ASCS was directly applied to partial-thickness burns or in combination with widely meshed STSG for full-thickness burns. Post-operatively, the treated areas were dressed with high-density polyethylene (HDPE), bismuth-petroleum gauze (BPG), and an absorbent gauze layer that were secured in place with retention dressings. On POD2 and POD4, all outer layers of dressing were changed, leaving only the HDPE in place. If there was concern for infection, a silver-impregnated dressing was substituted for the BPG. On POD6, all dressings were removed and replaced with daily BPG or emollients.ResultsThere were 243 wounds treated in 27 patients. The mean age was 24.6±19.3 years, with 52% being male and 48% female. Burn size ranged from 20–91% TBSA (mean 50±16%). At 8 weeks postop, 96% of the evaluable wounds had ≥95% wound closure. Minimal re-grafting was required in 10% of the wounds. Twenty-nine (12%) wounds required scar contracture release.ConclusionsThe gold standard for skin grafting has been STSG, and numerous post-operative dressings serve as acceptable options in the burn community. ASCS is a new, relatively delicate grafting technique. The wound care following the use of ASCS is critical to achieve optimal healing outcomes. Its delicacy should not discourage providers, as we have shown remarkable results with optimal wound healing using a minimal-cost and low-maintenance dressing regimen.Applicability of Research to PracticeAn Autologous Cell Harvesting Device is now FDA approved and will be available for greater use. It is important to share experiences and knowledge gained with others burn care providers to ensure optimal outcomes for all burn patients.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.108
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 370 Evaluating the Efficacy and Safety of Intraoperative Enteral Nutrition
           in Critically Ill Burn Patients: A Systematic Review and Meta-Analysis
    • Authors: Pham C; Fang M, Collier Z, et al.
      Abstract: IntroductionLarge burn injuries incite a hypermetabolic response that increases basal calorie requirements up to 140%. Caloric deficits and resultant malnutrition causes loss of lean body mass that perpetuates an immuno-compromised state and leads to a significant increase in graft failure, wound infections, and mortality. Optimal nutritional therapy reduces such complications, stressing the importance of early enteral nutrition (EN). Perioperative fasting can lead to cumulative caloric deficits over time, which can be ameliorated by intraoperative enteral nutrition (IEN). One concern of IEN is aspiration and an uncertain risk benefit ratio. Because of this, we conducted a systematic review and meta-analysis to evaluate the safety and efficacy of IEN.MethodsThe guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses were employed for this study. A systematic literature search was performed by two independent reviewers using PubMed, Scopus, and OvidSP MEDLINE databases as well as manually checking the reference lists of retrieved articles and reviews once article relevance was determined. We performed a meta-analysis on the incidence of mortality, pneumonia, and wound infections in patients who received IEN.ResultsWe identified 1,414 non-duplicate articles, of which 56 were included in the full-text analysis. After full-text analysis, five and four articles were included for qualitative and quantitative review, respectively. All articles were Level IV evidence. There was a total of 97 patients that received IEN. Based on the limited sample size from the articles retrieved, there were no statistically significant increases in the risk of mortality (OR=1.3, 95% CI 0.5, 3.3), pneumonia (OR=2.1, 95% CI=0.7, 6.1), or wound infection (OR=0.7, 95% CI, 0.2, 3.2). In all studies, patients receiving IEN were delivered more calories than standard fasting patients.ConclusionsIEN may be safely delivered in select burn patients without an increase in complications, although the studies are limited and of low quality. The benefits of nutritional therapy in burn patients are well-established and indisputable. IEN deserves special attention, as it presents a simple and straightforward means to improve nutritional supplementation and improve hospital outcomes. However, it is not without risk and may be logistically difficult to implement at many institutions due to concerns for aspiration and dogmatic perioperative fasting protocols. Although IEN shows great promise, trials clarifying safety and efficacy are needed before widespread adoption of this practice begins.Applicability of Research to PracticeIEN may be considered on a case-by-case basis in burn patients requiring nutritional therapy.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.278
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 512 Use of Artificial Dermis as a Wound Bed for Cultured Keratinocyte
           Sheet Cultured Using Temperature Response Dishes in an Ovine Burn Wound
           Healing Model
    • Authors: Niimi Y; Alharbi S, Fukuda S, et al.
      Abstract: IntroductionFor treatment of burn patient, shortage of both cadaver or autologous skin to cover large wounds are serious problems. Artificial dermis (AD) has been tested for wound bed preparation with cultured epidermal autografts (CEA). However, low CEA acceptance has been a challenging problem. The goal of this study was to compare the efficacy of AD and cadaver skin in preparation of burn wound beds for grafting with CEA. We hypothesized that the efficacy of AD is comparable with those of cadaver skin.MethodsTotal 12 full thickness burn wounds in 3 sheep (5 × 5cm) were induced at the dorsum of sheep. After 24 hours, the eschar was excised down to the fascia, and the wounds were randomly allocated to 2 groups: 1) covered with ovine frozen cadaver skin (n=6); and 2) covered with AD (n=6). The grafts were covered with pressure bandage for 7 days. Thereafter the wounds were opened and monitored for 14 more days (total 21 days). At the escharotomy, healthy skin was harvested for CEA. CEA were cultured in temperature-responsive dishes to avoid use of harmful enzymes for detachment. These sheets were overlaid into the burn wounds covered with either cadaver skin or AD at 3 weeks after injury. The re-epithelialization rate after CEA was assessed for 14 days using intermittent planimetric assay and histological analysis.ResultsNo complications (i.e., wound infection, hematoma) were noted in all wounds. Epidermis of grafted cadaver skin showed signs of rejection after 10 days, and its complete rejection was observed ~at 21the day. While, AD was gradually engrafted into the wound tissue, and converted to dermis-like tissue within 21 days. There was no significant difference between cadaver skin and AD re-epithelialization rate at 7 days and 14 days after CEA (55±12.8 vs. 52±15.5%, p=0.5, 89.1±6.4 vs. 82.6±8.5 %, p=0.07, respectively) (Figure).ConclusionsOur results suggest that the combined use of AD and CEA sheets (detached without enzyme) can be successfully used as a skin substitute for burn wounds. Further investigations are warranted to further improve healing rate in AD plus CEA for burn wounds.Applicability of Research to PracticeThe results are highly translational to the clinical practice.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.402
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 274 Occurrence of Psychiatric Illness and Problematic Substance Use among
           Frostbite Patients in an Urban Verified Burn Center
    • Authors: Iwaniec M; Gilbertson A, Belacic H, et al.
      Abstract: IntroductionHigh concordance rates of frostbite injury, substance abuse, and psychiatric illnesses among patients receiving specialized burn treatment have been acknowledged in both scientific literature and clinical lore. Despite this, no recent study has been conducted documenting this phenomenon, and there are no published protocols to guide management of psychiatric comorbidities. Review of the literature shows the last such study was published in 1997. Although understood to be a problem, the challenge of effectively addressing psychosocial factors related to frostbite injury and care has received little attention.MethodsTo explore the frequency of identified psychiatric diagnoses among patients, this study examined a limited time course (2012-2018) of both inpatient and outpatient clinical records of adult patients treated at an urban verified Regional Burn Center for frostbite injury.ResultsA total of 39 patients met inclusion criteria. The patient population was predominately male (77%), with a mean age of 42.5 years (range 22-74 years). Twenty-two patients (56%) were admitted to the burn center and 17 patients (44%) were treated as outpatients. Of the 39 patients reviewed, 65% self-reported substance abuse and/or a preexisting psychiatric illness.ConclusionsConsistent with previous findings, high rates of preexisting psychiatric illness and substance abuse were identified. Results highlight the importance of initial psychiatric and substance abuse screening for identified frostbite patients. If further indicated by screening, full utilization of available social work, psychological, and/or psychiatric services for clinical assessment and treatment recommendations (both while hospitalized and post discharge) is strongly recommended.Applicability of Research to PracticeThis study supports a routine psychology and/or psychiatry consult for frostbite patients due to high concordance rates of substance abuse and psychiatric illness.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.195
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 225 The Bridle: Optimizing Enteral Nutrition and Decreasing Costs
    • Authors: Ballecer A.
      Abstract: IntroductionOBJECTIVE: The objective is to prevent inadvertent nasoenteral tube displacement by using the bridle nasal tube retaining system in the burn patient. BACKGROUND: The burn patient requires high caloric intake and often meets criteria for supplemental nutrition via nasoenteral feeding tubes. Facial burns, altered mental status, and long term use of feeding tubes contribute to nasoenteral tube removal. These removals often result in a gap of nutritional intake, radiation exposure, increased risk for aspiration, patient discomfort, and increased nursing workload. Reinsertion of enteral feeding tubes is also shown to be cost-intensive. These costs are incurred from additional tube use and radiologic procedures. Additional costs of nursing workflow are not quantifiable however. Enteral feeding tube securement is the greatest challenge in preventing tube displacement. The standard securement with twill ties, or tape, has not been proven effective in preventing dislodgement.MethodsBridle education was provided to all burn center nurses via educational in-services, instructional video, and dissemination of a brochure reference tool from the bridle manufacturer. Bridle competency was measured by return demonstration via mannequin and patients, verbal understanding, and troubleshooting scenarios.ResultsDuring the three months prior to bridle initiation, there were seven patients requiring enteral nutrition via nasoenteral tube. A single nasoenteral feeding tube costs $58.80. Each abdominal radiograph and radiograph reading to confirm placement cost $72 and $26 respectively. There were eleven occurrences of inadvertent nasoenteral tube removal during this time period with a total cost of $1,423.26. These eleven occurrences required eleven abdominal radiographs to confirm tube placement. The bridle system was used in the burn center for the following four months. During that time, there were fifteen patients requiring enteral nutrition via nasoenteral tube. There were two occurrences of inadvertent nasoenteral tube removal with a total cost of $316.28. One of the dislodgments was due to user error. Therefore, there were only two abdominal radiographs related to tube dislodgement during this period.ConclusionsThe results showed a decreased cost of $1,106.98 and decrease in abdominal radiographs occurrences related to nasoenteric tube placement. Implementation of the nasal bridle tube retaining system reduced burn center costs, decreased the occurrences of nasoenteral tube removal, and lowered patient radiation exposure.Applicability of Research to PracticeThis project shows the bridle is a cost effective method of securing feeding tubes in burn patients.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.153
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 22 Minority Pediatric Burn Patients are Different than their Caucasian
           Counterparts and have Different Outcomes
    • Authors: Rotta S; Liu Y, Baldea A, et al.
      Abstract: IntroductionSocioeconomic disparities have a disproportionate impact on minority racial groups in many facets of health. With respect to pediatric burn injury, current literature on the impact of racial and socioeconomic disparities demonstrates mixed results. For our approach we pooled data from two diverse burn centers to determine if outcomes in pediatric burn patients were adversely impacted by a patient’s race and/or socioeconomic status.MethodsA 10 year (2004–2014) retrospective chart review was performed of all patients <18 years of age admitted to two ABA verified burn centers. Data collected included: age, race, gender, %TBSA burn, in-hospital mortality, length of stay, length of stay per %TBSA burn (LOS/TBSA), and zip code. Census data was used as an economic marker for patients based on their zip code: % of patient households below the poverty line, median income, and % of high school graduates in each patient’s community was determined. ANOVA and chi-square statistics were applied. Both univariate and multivariate analyses were performed and expressed as mean ±SD.Results2625 pediatric patients were analyzed. Mean age was 4.37±4.9 years and 60.2% were male with a mean %TBSA of 6.11±8.3%. Overall mortality was 0.99% and 2.44% sustained an inhalation injury. The racial representation consisted of 1168 (44.5%) Caucasian, 632(24.1%) Black, 508(19.4%) Hispanic/Latino, 68 (2.6%) Asian, and 239 (9.1%) Other. Results of univariate analysis by race are presented in Table 1. On multivariate analysis, a difference between race and mortality was not observed. However, Black patients experienced longer LOS compared with all other races (p<0.01) and longer LOS/TBSA compared to all other races except Hispanics (p<0.01).ConclusionsBlack patients are more likely to come from poverty stricken socioeconomic backgrounds in which fewer community members graduated high school. Hispanic patients come from similar disadvantaged situations. After burn injury, these groups demonstrated either a longer LOS, longer LOS/TBSA, or both, which suggests that resources within the home community of a pediatric patient have a considerable impact on their ability to safely leave the hospital.Applicability of Research to PracticeThis study identifies a group of patients that could benefit from earlier intervention with regard to wound care teaching, injury education, and may need additional allocation of resources at the time of discharge.Table 1:Univariate analysis by Race, Black race as referenceCaucasianBlackHispanicAsianOtherAge (years)5.57 +/- 5.6**4.03 +/-4.42.91 +/-3.6*2.57 +/-3.13.19 +/- 3.8*LOS (days)4.89 +/-8.6*5.63 +/-8.24.38 +/-11.1**3.26 +/-4.6**6.12 +/-30.2%TBSA6.63 +/-8.76.15 +/-8.75.05 +/-6.8**5.69 +/-6.05.51 +/-5.6LOS/%TBSA0.98 +/-1.5**1.30 +/-1.91.34 +/-8.10.76 +/- 0.93*2.09 +/-15.1**% Individuals below poverty level11.5 +/-6.9**23.7 +/-10.417.7 +/-7.4**12.0 +/- 7.4**14.4 +/-7.8**Median Household Income ($)63792.60 +/-21717.5**44117.45 +/-18198.652559.50 +/-15107.0**68021.25 +/- 22239.9**58683.09 +/- 21672.2**% High School graduation or higher89.2 +/-9.1**82.1 +/-9.275.1 +/-12.9**88.9 +/- 8.1**87.0 +/- 9.8***p<0.05**p<0.001
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.026
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 322 Using a Learning Module to Improve Nursing Knowledge of Positioning
           and Splint Application in the Burn Unit
    • Authors: Gloger A; Evans A, Ellsworth B.
      Abstract: IntroductionIn September 2017, the burn unit physical and occupational therapists noticed that the nursing staff was applying patient splints incorrectly, not applying them at all, and/or losing the splints between room transfers, wound care, and trips to OR. In the burn unit, improper splint application can lead to loss of function in affected areas of the body and increased length of stay. The situation was communicated to the burn unit nurse manager and burn unit nurse educator.MethodsA team consisting of an occupational therapist, physical therapist, and burn unit nurse educator met and developed a list of high-risk splints that the nursing staff was struggling with the most. It was then decided that the best way to deliver the material to the staff was through a Pathways learning module with embedded videos showing how to properly position patients and apply the splints. In order to assess learning, an anonymous survey monkey was sent to the burn unit staff before and after completing the module. The survey monkey consisted of ten questions that tested basic knowledge of applying different high-risk splints for burn patients.ResultsThe pre-test had 40 responses, with an average score of 75%. The post-test had 31 responses with an average score of 84%. Staff has also commented that they liked watching the videos of how to properly position the patient and apply each splint. The occupational and physical therapists have reported a decrease in the improper positioning and application of patient splints, loss of splints, in addition to an increase in the patient wearing their splints at ordered times.ConclusionsUsing a learning module improved nursing knowledge of positioning and splint application, in addition to other benefits such as reduction of losing splints. It was beneficial for the nurses to have the content in a learning module as they could always refer back to the module if they had questions about positioning or splint application.Applicability of Research to PracticeImproving nursing knowledge of positioning and splint application has the potential to decrease contractures, improve mobility, and decrease length of stay.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.235
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 423 Identifying Burn Patient Challenges with Implementation of Follow-Up
           Phone calls
    • Authors: Emanuel M; Laird J, Savetamal A, et al.
      Abstract: IntroductionAfter hospitalization, some burn patients find the transition to the outpatient setting to be challenging. Patients are sometimes overwhelmed by discharge instructions and can miss many important details. As a result, some patients have experienced graft failure or infection due to poor wound care, ineffective pain control, or inadequate out-patient services. We have implemented follow-up phone calls to all discharged patients to attempt to improve patient outcomes.MethodsThe pilot study of follow-up phone calls ran for four months. During this time, every patient seen or discharged from the Burn Center received a phone call from the assistant nurse manager within a week of discharge. Topics for the phone call included: general well-being, dressing changes, understanding of discharge instructions, medication, ancillary services including skilled nursing and occupational and physical therapy, and assistance with follow-up appointments. The need for and type of intervention subsequently undertaken was recorded.ResultsFifty-two patients were included in this study, 21 (40%) of whom required intervention. Six (11.5%) had VNA that did not arrive or VNA nurses who were uncomfortable caring for the patient’s wounds. Nine (17.3%) needed interventions with either dressings or prescribed medications. Ten (19.2%) had either expedited wound center visits or new appointments made due to pain or infection risk.ConclusionsDespite detailed written discharge instructions and verbal review of those instructions prior to discharge, patients often require further assistance to obtain optimal care when they leave the hospital. By implementing routine follow-up telephone calls with discharged patients, we were able to identify patients requiring assistance. These included issues such as making post-discharge appointments, arrangements for services (skilled nursing visits; occupational and physical therapy), and the need for medication adjustment. This intervention also assisted with early detection of patients who had difficulty with dressing changes and showed signs of infection or graft failure, and expedited follow-up care in the outpatient setting. We conclude that the follow-up phone calls helped to identify and address challenges that arise for a significant number (40%) of patients and families when being discharged to home. Continuing research will determine if follow-up phone calls help prevent readmission rate and infection rates post-burn.Applicability of Research to PracticeEarly identification of potential issues that may complicate the patient’s both short and long term outcome. Evaluating the relevance of patient challenges will improve patient outcomes.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.320
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 62 Social Skills Training for Burn Survivors: Needs Assessment and Program
           Evaluation
    • Authors: Holavanahalli R; Kammerer Quayle B, Peterson P, et al.
      Abstract: IntroductionSocial Skills Training (SST) program is one of few educational interventions specifically designed to facilitate successful community re-entry among burn survivors. SST focuses on the burn survivors’ psychosocial rehabilitation and social reintegration, especially the transition from the burn center to home. The purpose of this study was to conduct a needs assessment and evaluation of the SST program.MethodsData were collected during SST programs conducted at 5 locations. A 23-item questionnaire (12-item Needs Assessment and 11-item program evaluation) developed for the purpose of this study was used. The program evaluation component was administered to participants before and after the training to assess their level of comfort in providing SST to burn survivors regarding how to cope with social challenges in public such as responding to questions, staring, teasing; starting/ending a conversation; entering a social setting. The training also provided information regarding supplementary support resources, including use of cosmetic techniques for facial scars. A paired t-test was conducted to observe changes in attendees’ preparedness or level of comfort following the training to provide SST for burn survivors.ResultsAttendees (n=109) were predominantly nurses (38%) and therapists (16%) followed by other members of the burn team. About 83% of those surveyed thought it was extremely important to provide SST to burn survivors and 91% reported that it should be provided to all patients and families irrespective of need or request. Eighty-three percent of those surveyed report that they do not routinely provide SST because of lack of training (58%) or access to standardized information and tools (25%). Results of the paired t-test (pre- and post-test) showed that the mean post-training scores on all 11 items increased significantly (p<.0001) from pre-training, indicating an increased level of comfort among trainees to provide SST to burn survivors.ConclusionsThe findings in this study demonstrate an overwhelming need for a uniform or standardized program to facilitate community re-entry among burn survivors and SST is an intervention that can be readily used for such a purpose. The crucial next steps are to evaluate the sustainability of the training among the burn staff in providing these resources and to evaluate SST as an intervention in addressing social reintegration among burn survivors.Applicability of Research to PracticeThe findings from this study underscore the importance of aftercare and reintegration services to facilitate burn survivors’ successful community re-entry.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.065
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 465 The Impact of a Multi-Disciplinary Burn Education Course
    • Authors: Richardson E; Owens M, Nakamura D, et al.
      Abstract: IntroductionSpecialized care of burn survivors spans the care continuum. Inquiries from multi-disciplinary clinicians within our Burn Center’s catchment area led us to suspect knowledge gaps and decreased confidence in treating burn-injured patients. To bridge the identified gaps and to ensure optimal outcomes following burn injury, an education course was developed to target clinicians who provide post-acute burn treatment.MethodsThe course was interdisciplinary in nature and focused to address the multifaceted aspects of recovery from burn injury. Involved disciplines included counseling, nursing, occupational therapy, physical therapy, speech-language pathology (SLP), and a surgical physician assistant. We partnered with our local Area Health Education Center (AHEC) to implement a course entitled “Burn Care: Multi-Disciplinary Journey Through Acute Care, Outpatient, and Beyond.” Topics included: medical, wound, scar, and outpatient pediatric management, the role of SLP, exercise interventions, and psychosocial factor considerations.ResultsThere were 48 attendees. A pre-test and a post-test composed of 12 questions were completed to measure knowledge outcomes. Forty-one attendees responded (85%). Course evaluation included data on the effectiveness of each presentation and specific ways in which attendees would change their practice, as well as future learning needs. Responses were largely positive. A follow-up assessment is planned at 3 months.ConclusionsThis course highlighted the enthusiasm of attendees in learning about effective burn treatments to improve patient care practices for this population. Positive citations indicated this course provided resources for future reference and expressed interest for in-depth education that builds on this content. We believe there is an opportunity to provide basic knowledge, as well as advanced knowledge and skills to community providers. This course provided networking opportunities to build our referral sources and have face-to-face contact with our community providers.Applicability of Research to PracticeThis course supported our hypothesis that there is an interest in and need for burn education. The interdisciplinary nature of the course enhanced the learning experience relative to understanding roles and providing core burn information; however, this limited the depth of discipline-specific content. AHEC provided a mechanism for targeting in-state clinicians; however we found an opportunity to expand advertising to neighboring states within our catchment area. We plan to expand the course to provide education targeted at a range of skill levels, incorporating more hands-on activities, and marketing to adjacent states.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.360
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 369 Rapid tPA Therapy for Treatment of Severe Frostbite of the Upper
           Extremity
    • Authors: Subichin M; Lou R.
      Abstract: IntroductionSevere frostbite of the upper extremity is a devastating disease process. Historically, this has been managed with rewarming and expectant management resulting in high digit amputation rates. Strategies have now emerged to improve frostbite care including the use of anticoagulation and thrombolytic therapy. Unfortunately, these protocols are often delayed by the use of angiography and nuclear medicine bone scans. We established a protocol that involves rewarming followed by rapid tPA infusion. We sought to determine the utility of rapid thrombolytic therapy for severe frostbite of the upper extremity.MethodsWe reviewed patients who presented with frostbite of the upper extremity to the Burn Institute at Akron Children’s Hospital who underwent our protocol. Six patients were identified who received thrombolytic therapy immediately after rewarming for frostbite of the upper extremity. One additional patient did not undergo tPA because they presented greater than 48 hours after injury. Patients were considered ineligible for tPA protocol if they had significant trauma or major risk of bleeding. Our thrombolytic regimen includes intravenous systemic tPA bolus and infusion, followed by 2 weeks of therapeutic enoxaparin. All patients were evaluated at outpatient follow up for need for amputation. We collected digit involvement, patient demographics, complications from tPA, and the need for digit amputation after therapy. A historic patient group was used for comparison. ANOVA and fisher’s exact test were used for all analysis.ResultsAll 6 patients successfully completed the thrombolytic protocol including anticoagulation. In comparison to the historic group, there was no differences regarding age, gender, or severity of injury. A total of 60 digits were involved with severe frostbite (grade III or IV frostbite). Of the 60 digits involved, 46 digits were salvaged. In comparison to historic salvage rates, tPA lead to significantly more digit salvage (50% vs 77% p<0.01).ConclusionsOur experience shows that there is a high success rate of digit salvage when empiric tPA is used. We recommend the use of tPA at presentation without the use of nuclear medicine imaging or angiography.Applicability of Research to PracticeThe use of tPA at the time of presentation of severe frostbite should be considered without the use of adjunct imaging modalities.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.277
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 106 A Low-Cost Simulation Model and Instructional Video for Escharotomy
           Training
    • Authors: Thomas M; Curtis E, Stewart B, et al.
      Abstract: IntroductionIn the acute management of deep circumferential or near-circumferential burns of the extremities and chest, escharotomy is the only effective surgical intervention to alleviate impending vascular compromise and relieve chest constriction. In resource-limited environments such as low- and middle-income countries (LMIC) and military deployments where evacuation may be delayed, prior training in the proper performance of escharotomy is essential as this is both an infrequent and high-risk procedure. The objective of this study was to validate a previous described escharotomy model and examine whether it enhanced self-efficacy, knowledge and skill of medical personnel.MethodsIn-hospital and pre-hospital medical personnel, with varying degrees of burn care-related experience, participated in a one-hour training session. The first portion consisted of an introductory video presentation describing the indications, preparation, steps, pitfalls and complications associated with escharotomy. The second part of the training consisted of a supervised hands-on simulation with a low-cost ($75 supply cost plus manikin) and low-fidelity escharotomy model (figure 1). Students were then queried using a psychometrically validated student learning and self-confidence in simulation questionnaire (National League of Nursing, 2003). The questions focused specifically on simulation design, knowledge, active learning and realism.ResultsTwenty-two participants were grouped according to burn experience: burn attending physicians (4), general surgery residents (9), medical students (6) and pre-hospital personnel (3). Ninety percent of participants (20/22) thought their self-efficacy to perform and understand the role of an escharotomy was enhanced. Ninety-five percent of participants (21/22) reported that the teaching model provided an interactive learning opportunity that simulated a real-life scenario.ConclusionsSimulation training using this low-fidelity model allowed acquisition of necessary skills to simulate an escharotomy. This teaching model is easily reproducible, cost effective and can be used to increase the self-efficacy, competency and knowledge of medical personnel before they are called to perform actual escharotomy procedures.Applicability of Research to PracticeStudies to validate low-cost, low-fidelity simulation strategy are necessary to target burn care training in resource-limited environments.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.107
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 224 Creating a Burn Unit Orientation Manual Using the ABA Burn Nurse
           Competencies
    • Authors: Gloger A.
      Abstract: IntroductionOrienting new burn nurses can be very difficult given the specialized nature of burn nursing. In our academic, ABA-verified burn unit the orientation of a new burn nurse consists of a generalized hospital orientation, participation in a nurse residency program, and attendance of a two day burn class. However, it was noted that an evidenced-based reference with a focus on burn nursing was missing during this process. The aim of this project was to create a burn unit orientation manual using the American Burn Association (ABA) Burn Nurse Competencies as a framework.MethodsUsing the ABA Burn Nurse Competency statements as section headers, evidenced-based information from peer-reviewed burn publications was then used to “answer” each competency statement and essential performance criteria. Where appropriate, hospital-specific information was discussed, ensuring that the document not only reflected burn nursing on a global scale, but on a local scale as well. Construction of the manual began in May 2018 and ended in September 2018. In September 2018, the manual was then vetted by members of the Burn Unit Nursing Leadership to ensure that the manual accurately reflected the practices of burn nurses, as directed by the ABA Burn Nurse Competencies.ResultsThe resulting manual that was vetted was shown to be not only a complete and thorough orientation manual for new employees, but also an ongoing reference outlining the competencies and expectations that exemplify a “Burn Nurse”. The Burn Unit Nursing Leadership was in agreement that the manual was ready to be utilized by the burn unit nurses.ConclusionsThe orientation and education of burn nurses continues to be a laborious process, often with limited evidenced-based resources pertaining to the nursing care of a burn patient. Using the ABA Burn Nurse Competencies provided the framework to create such a resource for our burn unit’s nursing staff. This will help ensure that nurses have an evidenced-based resource to help direct their care of burn patients.Applicability of Research to PracticeCaring for a burn patient requires knowledge that is specific to burn nursing, as they are a unique patient population with their own intricacies. Having a resource that is evidenced-based will ensure that burn nurses are getting accurate information on how to care for their patients that meets the standards of the ABA.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.152
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 21 A Case-Controlled Retrospective Review of Burn Patients Meeting
           American Burn Association’s Verified Burn Center Referral Criteria
    • Authors: Murray D; Richey K, Baker M, et al.
      Abstract: IntroductionRegulatory and advisory bodies have published guidelines that trigger patient referral to a verified burn center. Despite these easily referenced resources, non-verified burn units admit and manage patients who meet burn center referral criteria. This may deny patients access to appropriate multidisciplinary care, increase their risk of complications, and increase the cost of care. The purpose of this study was to describe several characteristics and sequelae of patients with delayed referral (DR) to a verified burn center compared to patients who were immediately referred.MethodsThis was a matched case-controlled retrospective study of inpatients who met 1 or more referral criteria to a verified burn center but were delayed in their referral from 2012–2017. Patients who had DR were compared to those who were referred within 3 days (IR). Cases were matched on age, total body surface area (TBSA) and ABA referral criteria. Basic descriptive statistics were calculated.ResultsOf the 3,759 patients who were admitted during the study period, 60 had delayed referrals and all were successfully matched. There was no significant difference in past medical history. DR were seen on average at 7.6 days post-injury as compared to 0.45 days IR (p < .0001). There was no significant difference for the specific referral criteria, burn location, discharge disposition or between those with a payor source and those who were uninsured. However, for patients with a payor source those with private insurance were more likely to have a DR (p = .045). Flame/flash injuries were more likely to be immediately referred (p < .001) and contact burns were more often delayed (p < 0.001). Females were more often DR than males (p = 0.009) as were non-minorities (p = 0.042). DR had longer hospitalizations 17.67 days vs 10.83 (p = .023) and required surgery more often 47 vs. 28 (p = .0003). DR suffered more acute complications 27 vs 7 (p < .001) and more long-term complications 20 vs 10 (p = .034).ConclusionsBased on our data, DR results in increased surgeries, increased lengths of stay, and more complications. All these factors are associated with increased cost of care and increased nosocomial risk for patients.Applicability of Research to PracticeEliminating DR may have a significant positive impact on the cost and morbidity of burn care.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.025
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 321 Perceived Value of Knowledge Translation Intervention Designed to
           Facilitate Burn Survivors’ Work Reintegration
    • Authors: Calva V; Seto V, Lamble M, et al.
      Abstract: IntroductionReturning to work can be a substantial challenge for burn survivors. Approximately 28% never return to any form of employment, resulting in lower health-related quality of life. In other conditions, open communication has been identified as a facilitator for return to work (RTW). A knowledge translation (KT) intervention in the form of an educational video was developed for adult burn survivors to facilitate their RTW and promote communication with co-workers and employers. Following its implementation, the impact on the RTW process needed to be evaluated, thus a mixed methods, cross-sectional study was performed.MethodsBurn survivors included in the KT intervention were recruited and compared to a control group (CG). The CG included burn survivors who were admitted prior to the development of the educational video or who did not have an opportunity to review the video due to the timing of their transfer to another facility or rapid discharge. The CG were selectively invited to participate so that the two groups’ mean age, gender and percent total body surface area burned were similar. Semi-structured interviews were conducted to gather information about their RTW process and outcomes. Qualitative data was analyzed through thematic analysis and quantitative data was summarized and compared using Mann-Whitney tests.ResultsOverall, both groups were satisfied with their RTW process. Participants from the CG identified more barriers related to support received, particularly at work. More participants from the CG also indicated psychological symptoms and social challenges such as post-traumatic stress disorder, self-consciousness and discomfort with questions as a barrier to RTW. Many participants from the KT group indicated that the video gave them tools to explain and provide others with a better understanding of their lived experience.ConclusionsIt is possible that the video facilitated more open communication by empowering burn survivors to explain their situation on their own, thus reducing the prevalence of social and psychological barriers among the KT group by allowing them to self-advocate for more support.Applicability of Research to PracticeThe video should continue to be used, however, it should be expanded to provide additional information about RTW facilitators such as progressive RTW, flexible schedules, and task modifications or accommodations.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.234
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 272 Creative Adult Centered Activities in The Hospital Setting
    • Authors: Henry S; Haskill S, Castro A, et al.
      Abstract: IntroductionOver 30,000 patients are hospitalized yearly in burn centers throughout the United States.With approximately 70% of Burn Center inpatients admitted as adults, there is a need for adult programs for patients of varying physical, cognitive, and social abilities. An interdisciplinary team at our institution recognized the need for the regular outlet and sought to develop a program that encouraged social interaction, and provided a platform to share common burn experience while participating in structured group activities.MethodsFrom 2016 to 2018 our ABA verified Burn Center offered weekly adult activities that were open to hospitalized patients and their family and friends., regardless of physical and cognitive abilities. The program was advertised by staff through printed fliers and verbal promotion. Phoenix Society SOAR (Survivors Offering Assistance in Recovery) and hospital volunteers were educated in burn recovery to help facilitate positive interactions with patients and assisted with weekly activities. Activities included different creative modalities, such as: painting, ceramics, clay molding, puzzles, board games, and creative journaling. Participants attended without charge and all supplies were donated by community partnerships with local fire departments or were funded by the Burn Center.ResultsPatients and community burn survivor groups provided positive feedback. Patients expressed gratitude and overall appreciation in having something to look forward to while hospitalized. Survivors acquired new coping mechanisms and creative modalities for self-expression. We noted greater staff satisfaction, increased interaction between patients and families, and increased demands for more organized activities.ConclusionsThe Burn Center provided enhanced adult centered activities while patients were being treated in the acute hospital setting. Through the use of SOAR and hospital volunteers there was no increase in paid staff hours. Participants reported benefits from these experiences as they expressed gratitude and an overall appreciation for the activities. The psychosocial affects and benefits of this regular interactive adult activity merits further investigation.Applicability of Research to PracticeAs a result of these early outcomes, we have developed a patient survey rating their experience. We are currently accumulating results to validate the overall patient experience of an adult activity program.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.194
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 464 Improving Pediatric Medication Safety in the Burn Unit
    • Authors: Pape K; Beyer J, Pauley A, et al.
      Abstract: IntroductionOf the 67 centers verified by the American Burn Association (ABA) in the United States, 38 centers care for both adult and pediatric patients. According to the Institute of Medicine, medication errors are the most common cause of harm in pediatric patients. Common errors can include prescription dosing, incorrect preparation, and administration errors.MethodsThe burn unit at our institution is the only unit in the hospital that houses both adult and pediatric patients. Several processes were implemented to improve pediatric medication safety on the unit. A patient chart advisory (PCA) now fires every time a pediatric chart is opened, alerting the provider that they are in the chart of a pediatric patient on an adult unit, displaying to the provider on the first page of the chart. Under the order entry function, a PCA fires for the provider again alerting them to the pediatric patient status, requiring their acknowledgement, and providing pharmacy contact information if dosing assistance is needed. This alert also fires for nursing staff in the event they are placing a verbal order. Pediatric medication cards were provided to both providers and nurses with common medication doses used. Nursing staff have also undergone education sessions focusing on pediatric safety. Other steps to improve safety included updating of order sets, creating burn unit specific preference lists for medication ordering, and changing of the patient banner within the computer system for pharmacists to alert a pediatric chart.ResultsSince the PCA was implemented one year ago, it has fired 3,282 times on 85 unique patients for 241 unique providers, including physicians, pharmacists, therapists, and nurses. A total of 7,553 medications have been administered to pediatric patients during this time. In the two years prior to the PCA implementation, there were 7 voluntarily reported medication safety events reported. In the last year, only one event has been reported, which was a dosing error caught by the pharmacist upon verification. This was prior to the creation of burn unit specific preference lists.ConclusionsOur hospital-specific interventions have decreased reported pediatric medication errors. Continued vigilance is needed from all disciplines to further decrease the risk to the pediatric patient population.Applicability of Research to PracticeCollaboration and idea sharing among burn units can help further identify deficits and processes that can be implemented to improve pediatric medication safety.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.359
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 509 Evaluation of Autologous Skin Cell Suspension for Definitive Closure
           of Extensive Burn Injuries in Adult Population
    • Authors: Hickerson W; Holmes IV J, Molnar J, et al.
      Abstract: IntroductionLack of available donor skin in patients with extensive burn injuries is often the central problem impeding operations for permanent closure. A recent pivotal randomized controlled trial (RCT) demonstrated the use of autologous skin cell suspension (ASCS) prepared using an ASCS device in the treatment of acute thermal full-thickness burn wounds (TBSA ≤50%) achieved comparable healing outcomes to conventional skin grafting, using significantly less donor skin (32% reduction). In the US, the safety and effectiveness of ASCS in acute thermal burn injuries in patients with >50% TBSA has not been established. The purpose of this study is to present preliminary data on the outcomes for adult patients with life threatening, >50% TBSA, burn injuries treated with the combination of meshed STSGs and ASCS.MethodsA prospective uncontrolled observational study was conducted under an Investigational Device Exemption (IDE 15945—NCT029992249) to evaluate healing outcomes and adverse events (AEs) following ASCS treatment in an adult population with life threatening burn injuries (compassionate use). Patients with a minimum of 8-week follow-up were included in the analyses.ResultsTwenty-two patients ≥18 years with >50% TBSA from 9 centers were treated with ASCS in combination with meshed STSG, totaling 150 wounds. Mean TBSA was 61.2% (range 52%-91%) and mean Baux score was 103.1±19.3. Thirty-five percent of wounds were treated with widely meshed autografts (4:1 or greater) and ASCS, and 53% of wounds were treated with a dermal substitute prior to meshed epidermal autograft and ASCS.At 8 weeks, 96% of wounds achieved healing (≥95% re-epithelialization) compared to 87.2% of wounds in the pivotal RCT (wherein healing was defined as 100% re-epithelialization confirmed at consecutive visits). Surgical intervention was required for graft failure in 8% (12/150) of wounds and for contracture release in 3.3% (5/150). No AEs were reported as related to the ASCS treatment.Subjective assessment of wound appearance by the physician at 1 year was available for 21 patients and color, pigment, and texture was reported as matched or mildly mismatched to uninjured skin for the majority of wounds, 83%, 78%, and 70%, respectively.ConclusionsASCS and meshed STSGs achieves definitive closure for patients with extensive burn injuries, with preliminary results suggesting comparable outcomes to subjects with less severe injuries.Applicability of Research to PracticeASCS is a novel autograft-sparing technology allowing immediate point-of-care treatment and should be considered for use as part of a surgeon’s algorithm for acute thermal burn injuries.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.401
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 368 Hypoglycemic Encephalopathy Secondary to Vitamin C Infusion in Burn
           Resuscitation
    • Authors: Sodomin E; Saquib S, Chestovich P, et al.
      Abstract: IntroductionVitamin C (VitC) infusion in acute burn resuscitation has been shown to decrease overall fluid requirements. Protocols have been implemented for use in many centers for burns with TBSA >30% for the first 24 hours of resuscitation. A sentinel event occurred during this infusion and compromised patient safety.MethodsWe present a critical complication of VitC infusion. The patient developed hypoglycemia, masked as hyperglycemia, resulting in hypoglycemic encephalopathy. This case describes the events and steps taken to prevent a recurrence.Results52 yo M presented following a mobile home fire from propane leak. He sustained 40%TBSA burns involving the bilateral legs, arms, and face. GCS was 15 at time of initial evaluation. The patient was intubated for airway protection due to evidence of inhalation injury. Parkland resuscitation and VitC infusion protocol were initiated.Trickle tube feeds were initiated and the patient was placed on Insulin sliding scale (ISS). He was hemodynamically stable with a GCS 11T. Overnight his point of care glucose (POCG) ranged from 158-240 mg/dL. On hospital day (HD) 1 POCG remained in the mid to high 200s, despite treatment with ISS. He was placed on an insulin drip. His POCG remained elevated and his insulin drip was increased accordingly. On HD2, his serum blood glucose was 5 mg/dL. It was rechecked and was 9 mg/dL, with the corresponding POCG 283 mg/dL. Insulin drip was stopped and D50 was administered. Total duration of drip was 12 hours 40 minutes, and the maximum dose was 23 units/hr. Following correction of hypoglycemia, the patient was GCS 3T. A Head CT was unremarkable, and a subsequent MRI brain showed acute demyelinating encephalopathy. Repeat imaging 10 days later showed bilateral basal ganglia acute stroke vs. anoxic brain injury. Patient did not fully recover his mental status. He ultimately decompensated from sepsis. Family elected to withdraw care on HD#24 and he expired.ConclusionsVitC alters the electrochemical reaction that generates a POCG reading. This case highlights the unreliability of POCG testing in VitC infusions with detrimental results.Applicability of Research to PracticeThis event prompted implementation of a multidisciplinary approach for education. Extensive instruction was provided to nurses and physicians with new protocols. Pharmacists modified our EMR to include safeguards with hard stops whenever insulin and VitC are being used together. With these changes, VitC is now safer to use in the resuscitation of critically ill burn patients.Glucose TrendsTime15:0017:0019:0021:0023:0001:0003:0005:00Drip (units/hr)348101518230POCG (mg/dL)264198276235258271232283Serum glucose (mg/dL)4059
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.276
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 223 The Use of the IPASS Handoff Communication Tool to Increase Nursing
           Satisfaction during Handoff on a Burn and Pediatric Unit
    • Authors: Caceres M; D’Aniello J, Lerew T.
      Abstract: IntroductionMultiple studies have established that the nursing handoff process is error-prone and disorganized. IPASS is a standardized handoff tool that has been proven to reduce medical errors but has limited validation in nursing. The objective of this process improvement, nurse-driven, pilot project was to evaluate the effectiveness of the IPASS standardized handoff system for nursing satisfaction/communication and patient outcomes on a burn and pediatric acute care unit within a regional referral hospital.MethodsThe IPASS handoff tool was adapted and tailored for the unit and hospital’s standards. Specific modifications included the addition of burn and pediatric items, safety checks, and patient/nurse interaction. The intervention was then rolled-out to all nursing staff on the unit. A pre and post-intervention survey was administered to staff nurses to assess the satisfaction and perceived quality of shift change handoff. Questions utilized a 5-point Likert scale; descriptive statistics were used for analysis. In-hospital patient clinical outcomes were tracked 6 months pre and post-project roll-out.ResultsThe project occurred over a two-year period between 2016–2018. Survey respondent characteristics are listed in the table below. Nurses reported a significant increase in satisfaction of shift change report after IPASS roll-out. Nurses reported an increase in the accuracy and understanding of the information received. A decrease in the amount of “gossip or venting” during report was also noted. The number of patient falls decreased by 13% during this review period. The percentage of ICU transfers after a rapid response alert for clinical deterioration decreased from 7% to 5%. No changes were found in infection rate, and length of hospitalization (LOS) increased slightly.ConclusionsIPASS utilization was shown to significantly increase nurse satisfaction and improve overall communication. This project is being considered for hospital-wide implementation as the standardized method of handoff for nurses.Applicability of Research to PracticeA standardized handoff tool can aid in increased nursing satisfaction and communication during the handoff process.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.151
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 105 Scar Quality of Skin Graft Borders: A Prospective Randomized Double
           Blinded Evaluation
    • Authors: Zuo K; Umraw N, Cartotto R.
      Abstract: IntroductionProminent scars may remain around the border of a mature skin graft (SG) at the interface of the SG and normal skin. The border of a SG may be constructed by either exactly approximating (A), or slightly overlapping (O) the edge of the SG on the wound margin. The purpose of this study was to evaluate whether A or O affects the quality of the border scar of SGs applied to burn patients.MethodsThis prospective study was a within-border design in which adult burn patients requiring SGs served as their own control. Half of each study border was fashioned using O and the immediately adjacent other half was made using A. We randomly assigned O or A to the proximal or distal halves of vertical borders and the medial and lateral halves of horizontal borders. Both halves of the study border were identically fixated with staples or sutures, and were managed in the same fashion postoperatively. Evaluations at 3, 6, and 12 months of O and A borders were performed by a blinded OT using the Vancouver Scar Scale (VSS), The Observer Scar Assessment Scale (OSAS), and a global binary assessment of which half of the study border “looked better”. Patients were also blinded and rated each half of the study border with a visual analogue scale (VAS). Values are reported as the mean ± SD or median (IQR), as appropriate.ResultsThere were 34 borders studied in 15 subjects [46.7% female, age 29 (22,57), % TBSA burn 9.7 ± 5.3, and no inhalation injuries]. Study borders were constructed at 7 (5,11) days post burn, had a total length of 12 (9.3, 14.5) cm, and all involved split thickness SGs of thickness 13 (12, 14)/ 1000th inches. Sheet grafts were applied in 27% and meshed grafts in 73%. SGs were applied immediately after excision in 75% or after allografting in 25%. Border scars matured between 3 and 12 months with reductions in total VSS from 8 (7,8) to 4 (3,6) for O borders (p< 0.001) and from 8 (7,9) to 4 (1,6) for A borders (p<0.001). However, there were no significant differences between O and A borders in total VSS at 3 months (p=0.165), 6 months (p= 0.602) and 12 months (p=0.358), or in total OSAS at 3 months (p=0.681), 6 months (p=0.890), or 12 months (p=0.601). At 12 months, 60% of O borders and 40% of A borders were globally rated as “better” (p = 0.258). There were no significant differences in the patients’ subjective ratings of the O and A borders at 3 months (p=0.914), 6 months (p=0.955), and 12 months (p=0.665).ConclusionsThe quality of the scar at the border of a skin graft does not appear to be affected by the surgical technique used to construct the border at the time of graftingApplicability of Research to PracticeBorders around skin grafts can be constructed either with an overlapping method or an approximating method. Both techniques appear to produce similar border scars.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.106
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 20 Bringing Burn Referral Criteria into the 21st Century: A Structured
           Expert Consensus Project to Update and Refine Recommendations for Transfer
           and Consultation
    • Authors: Bettencourt A; Carter J, Cartotto R, et al.
      Abstract: IntroductionThe Burn Referral Criteria of the American Burn Association were developed by consensus over 20 years ago to guide referring institutions in triage of burn patients and improve patient care. In the existing version, “referral” was not strictly defined, and has often been interpreted as “transfer.” Coupled with frequent errors in estimation of burn size and depth by non-burn centers, interpretation of the criteria as prescriptive has produced challenges in patient triage. Recognizing digital communication proliferation and the cost to patients and institutions of both under and over triage, we reasoned that the current criteria needed to be revisited. In the absence of compelling clinical trial data dictating burn triage, we convened a panel of experts in an iterative eDelphi consensus process to facilitate revision of the criteria.MethodsAfter IRB exemption, a panel of (n=61) burn experts including burn surgeons, intensivists, nurses, internists, advanced practice providers, emergency physicians and therapists from all ABA regions were invited to participate. Each participant received a 121 question survey. Consensus for any statement on the survey was defined as a % agreement of >70% among experts. Survey completion data were recorded anonymously in RedCap, and statistically analyzed using Stata IC v.15. After the initial survey, a second survey was distributed with those items not achieving the consensus (n=26) in round 1. Finally, a small and focused subgroup of the panel was enlisted to address the 16 statements that failed to achieve consensus in round 2.ResultsThe eDelphi Round 1 response rate was 90% and Round 2 was 100%. All of the new guideline recommendations reflect >70% agreement. Broadly, consensus is that the next iteration should be a guideline for referrals, consultations and transfers. Statements address triage of patients with various injury types (depth, size of burn, inhalation injury), recommendations for children and the elderly, and triage of non-burn diagnoses such as toxic epidermal necrolysis. Expert consensus also recommends expanding the role of telemedicine in the referral, consultation, and transfer process.ConclusionsThis process led to a robust, methodologically sound guideline for consultation and transfer of burn patients to burn centers. Expert consensus recommends burn center involvement in triage/ care decisions for most burn patients, with recognition that telemedicine greatly extends the reach and availability of burn center expertise. These overarching themes are present in the upcoming revision of the ABA Burn Center Referral Criteria.Applicability of Research to PracticeThis study directly addresses guidelines for burn care consultation and referral.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.024
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 422 Medical Photography: The Need for a Clinical Practice Guideline
    • Authors: Zoltie T; Blome-Eberwein S.
      Abstract: IntroductionHealthcare professionals are increasingly required to document clinical progression of patients which can strengthen wound assessments and documentation (Bradshaw et al, 2011). Healthcare teams are often supplied photographic equipment but limited resources are available for education and training of medical staff in photographic techniques and methods in order to achieve standardisation and apply these techniques at the bedside. This talk will demonstrate the need for training and the importance of accurate medical photography, offering a good practice guide to achieving accurate standardised photography of wounds and scarring.MethodsA short survey was sent out to residents and medical students, asking about training in medical photography. Unanimously the answer from 15 returned surveys was that no training was provided and that training was needed.There are several simple and basic principles to be considered when taking pictures to document a medical condition at the bedside: - Background- Focus- Lighting- Identification- Sterility- Informed consent- DecencyResultsThese principles will be elaborated upon in the presentationConclusionsSeveral simple guidelines can be followed in order to achieve reliable and impactful photographs at bedside. The need for training in these techniques has been documented.Applicability of Research to Practice: Immediate
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.319
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 320 A National Survey Regarding Utilization of the Burn Therapist in the
           Operating Theater
    • Authors: Lopez J; Meshanko J, Richey K, et al.
      Abstract: IntroductionPhysical and Occupational Therapists (PT/OT) are experts in biomechanics and deliver care through various modalities including range of motion (ROM), mobility, positioning, and splinting. Burn therapists have enhanced knowledge and experience with cutaneokinematics and are an integral part of the burn multidisciplinary team. Traditional rehabilitation therapies are performed at the bedside or in an outpatient setting, but burn care offers different venues. The operating room (OR) provides opportunity to deliver burn specific therapist interventions. The purpose of this survey was to describe the current practices and opinions of burn therapists regarding their roles delivering therapy care in the OR.MethodsAn internet-based 11-item survey was distributed to burn therapists at North American burn centers and units. Descriptive statistics were performed.ResultsThere were 52 respondents, 79% of whom worked at verified burn centers. All regions were represented including Canada, with the majority coming from the Western Region (33%) followed by the Northeast Region (23%). Interventions in the OR were performed by 92% of respondents and included ROM (81%), splinting (79%), graft management (35%), positioning (31%), dressing changes (23%), and wound care (15%). Twenty one percent of respondents performed all activities. The majority (71%) of therapist surveyed did not assist with the transfer of patients in the OR nor the positioning of limbs for autografting (65%). Most therapists (95%) were able to have open dialogue with providers and 70% were able to request procedural sedation and/or sedation vacation for therapy interventions. While 90% of respondents felt that it was beneficial to be in the OR, 35% did identify cost as a concern governing therapy time and availability in the OR.ConclusionsEncouragingly, 92% of respondents indicated involvement in the operative environment. More than half of respondents indicate involvement in range of motion and splinting. Interestingly, substantially fewer respondents indicated performing patient positioning or positioning for graft management. Our survey results suggest that while the majority of burn therapist respondents are extending the multidisciplinary model of care into the OR, they are typically delivering traditional therapy modalities when in the operating theater. Further research is warranted to explore variables contributing to this phenomenon.Applicability of Research to PracticeWhile burn therapists who responded to our survey are routinely involved in the OR, their knowledge of cutaneokinematics and biomechanics may not be fully utilized in the operative environment.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.233
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 61 The Use of Methadone Plus Gabapentin As a Multimodal Pain Regimen
           Compared With Traditional Pain Management Protocols in Burn Patients: A
           Retrospective Study
    • Authors: Ahnood E; Bradley B, Kesey J, et al.
      Abstract: IntroductionPain is unavoidable after burn injury and treatment to reduce the severity is critical to successful outcome. Yet traditional approaches using opioid narcotics with sedatives such as benzodiazepines trade pain and agitation control for serious side effects that would ultimately have a negative impact on the recovery goal. In October 2014 we switched to an analgesia approach using methadone and Gabapentin. We retrospectively reviewed the impact of this new pain protocol compared to the more traditional Morphine plus benzodiazepine therapy.MethodsA review of patients from 2013 to 2016 on the traditional therapy, compared to patients on the new program from 2014 to 2017. This review included an analysis of EHR for groups of 61 patients treated with methadone/Gabapentin (new program) as well as those patients treated with traditional opiate/opioids and benzodiazepines. Data was extracted for demographic information, wound severity, as well as assessment of level of pain management, nutrition tolerance, bowel function, and cost. Delirium and sedation measurements were acquired as RASS scores, and used as indicators for comparison between the two groups.ResultsThe two groups were equivalent in age, sex, ethnicity, BMI, diabetes and smoking. The methadone cohort had significantly higher total body surface area, yet their average reported pain level was significantly lower (P <0.033) and they required markedly less morphine equivalent doses (P <0.04). They also had significantly less frequent over sedation episodes (p<0.006), significantly improved bowel movements (P<0.001) with less episodes of constipation and late defecation, and significant reduction in cost (P<0.001) compared to the traditional group.ConclusionsAn analgesic-only, enteral, background pain management protocol with methadone and gabapentin is superior to the traditional pain control regimen. It provides a better pain control while significantly reducing many of the unwanted side effects of the traditional method.Applicability of Research to PracticeThe pain management protocol we describe in our research is a definite improvement from traditional pain management protocols in that it provides very adequate pain reduction while eliminating the problematic side effects caused by these traditional approaches.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.064
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 367 Final Results from the First Clinical Case Series for a Non-Invasive
           Imaging Device and Artificial Intelligence in the Classification of
           Non-Healing Burns
    • Authors: Baxter Jr R; Thatcher J, Nussbaum A, et al.
      Abstract: IntroductionAssessing severity of burns based on current clinical methods is difficult but critical in assuring appropriate and expedient burn care. We are continuing to develop a novel device which uses multispectral imaging (MSI) and artificial intelligence (AI) algorithms to aide in determination of burn severity and healing potential. Previously, we reported interim results of this proof-of-concept (POC) case series at the Southern Regional Burn Conference in 2018. We now present final results of this clinical study and demonstrate feasibility for training AI algorithms to predict non-healing burn.MethodsSubjects with various burn severities were enrolled within 72 hours of burn and imaged daily with our device up to 7 days post burn. True severity of burns in each image was determined using healing assessments at day 21 post-burn and punch biopsies obtained at time of surgery. The accuracy of the imaging device to identify and differentiate healing and non-healing burn tissue in first, second, and third degree burn injuries was analyzed. Using the accuracy results, we trained an AI algorithm to identify non-healing burn tissue. Evaluation of biopsy utilization in informing the truthing method for burns was also evaluated.ResultsData were collected from 25 subjects with 43 total burns and 303 images. The AI algorithm was trained and achieved a 90.0% sensitivity and 90.2% specificity in predicting non-healing burn tissue using cross validation. Example images for a non-healing burn on the anterior left thigh of an 86-year-old male taken 4 days post-burn injury appear in the attached figure.ConclusionsThe AI algorithm trained on 25 subjects had an area under the curve (AUC) of 0.965, compared to an AUC of 0.850 for 10 subjects. Future work is focused on initiating a multi-center study to collect a larger representative burn database used to further train our AI algorithm.Applicability of Research to PracticeThis study shows results from a completed POC study for developing an aid to burn assessments. Performance of AI algorithms trained on the data collected using our MSI device gives high confidence that clinically relevant predictions of burn healing potential are feasible using this technology.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.275
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 222 Decreasing Hospital Acquired Pressure Injuries (HAPI) with the
           Implementation of a Two Registered Nurse (RN) Skin Check during
           Hydrotherapy
    • Authors: Klecka E; Alem P, Dimler M, et al.
      Abstract: IntroductionPatients hospitalized for any significant length of stay (LOS) are prone to the development of pressure ulcers. Patients in burn intensive care units (BICU) are at increased risk due to diminished activity, impaired skin integrity, nutritional deficits, and edema. In addition, patients with large surface area burns also may also undergo several operative procedures and splint application. Routinely utilized prevention strategies, did not prevent all HAPIs. In our BICU, there was a pressure injury rate of 16.86% for the first three quarters of 2017. With the overall hospital rate reported to the National Database of Nursing Quality Indicators (NDNQI) as 4%, burn staff recognized an immediate need to intervene.MethodsEarly prevention and identification was targeted as an area for improvement with the goal of targeting zero HAPIs. The burn nursing management team collaborated with the program manager of wound care and the nursing unit based practice council. A practice change was created by the group called a “Tank-room Time-out”. Every patient admitted to the BICU receives a full skin assessment by two RNs. During this time a check list is completed by the two RNs. A binder that contains the burn diagram and a check list with all pressure areas for each patient is housed in the BICU hydrotherapy room. In addition, during each patient’s daily dressing change, a “time out” is called and a two RN head to toe skin check is performed. All other patient care activities are to be suspended during this “time out”. New findings are documented on the patient specific check list and the two RN skin assessment is documented in the electronic medical record. To standardize use of the check list and procedure, an education competency was developed for both BICU nursing staff and burn technicians. Content included the rationale for implementing this tool, examples of proper documentation and a review on how to correctly stage a wound. In addition, the protocol for discovery of a HAPI was included.ResultsEarly and frequent assessment and continuous documentation has significantly decreased the development of hospital acquired pressure ulcers within one year at our burn center. While comparing the HAPI rate for the first three quarters of 2017 to the first three quarters of 2018 there was a 7.32% decrease. The rate went from 16.86% to 9.52%.ConclusionsImplementation of a “Tank-room Time-out” tool has improved staff awareness for the risk of HAPIs among critical burn patients. The tool provides a standardized process for a two RN skin check of all BICU patients, which has resulted in a significant decrease in HAPI.Applicability of Research to PracticeThe use of a daily two RN skin assessment can lead to a decrease in HAPIs and better patient outcomes.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.150
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 463 Pressure Injury Prevention in a High Pressure World
    • Authors: Fischer S; Grantham D.
      Abstract: IntroductionPressure injuries are classified as never events. Burn patients with Braden Risk Assessment scores less than 16 are at risk for developing pressure injuries secondary to altered mobility, moisture, and shear/friction related injury, among many other factors. Despite utilizing evidence-based interventions, an increase in burn center pressure injuries - primarily to the occiput - were noted. Literature review, in conjunction with expert consultation, identified lack of standardization for the prevention of pressure injuries specific to burn patients.MethodsA pressure injury prevention protocol was developed for burn center use. A chronological sample of 13 adult patients with cutaneous injuries greater than 10% total body surface area, poor mobility, and/or need for mechanical ventilation were monitored for protocol effectiveness. An additional two patients were included in the review for continuous quality improvement. Patients were monitored throughout hospitalization with pressure injury prevalence recorded at discharge. In addition to standard evidence-based practice, the pressure injury prevention protocol includes the use of a fluidized positioning pillow to float the occiput, bordered foam placement to the sacrum and heels, elimination of braids to the posterior head, and shaving the head of those with major burns and/or burns to the head when intubated.ResultsPressure injuries occurred in only two of 15 patients. Patients with pressure injuries were identified as having deviated from the protocol. Both patients had their hair braided and the fluidized positioning pillow was not consistently utilized resulting in occiput pressure injury.ConclusionsThis prevention-based protocol decreased the number of pressure injuries potentially saving healthcare dollars, surgeries, and hours of wound care. More importantly, this protocol has allowed staff to promote better outcomes for burn patients when these complications were felt to be inevitable in the past. Further research is warranted to assess application of this protocol including for those with special considerations: pediatric, geriatric, and bariatric patients.Applicability of Research to PracticePresents a protocol to aid in compliance with pressure injury prevention to affect positive outcomes for both patient and organization.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.358
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 271 Support for Burn Survivors: Influential Factors in the Recovery
           Process
    • Authors: Dukes K; Baldwin S, Assimacopoulos E, et al.
      Abstract: IntroductionSurviving a burn injury involves a complex healing process. Unfortunately, there is not a ‘one size fits all’ method for supporting survivors through their recovery, and survivors often have difficulty getting the support they need. In this study, we sought to identify factors that were influential in the recovery process for burn survivors, especially relating to barriers in obtaining support.MethodsWe conducted thematic analysis on transcripts of in-depth, semi-structured interviews with 11 burn survivors who had been treated at a Midwest tertiary facility. Survivors were purposefully selected for variability in age, gender, injury size, injury mechanism and quality of life responses. Interviews were recorded and transcribed verbatim. All interviews were coded by at least two authors. Coded results were entered into MAXQDA, a qualitative data management software program.ResultsThe mean age of the survivors interviewed was 51 years (35-63 years) and time from the injury was 5.4 years (2 months to 26 years). Their burn sizes ranged from &lt10% in 4 survivors to 70-79% in one survivor. Survivors acknowledged profound ongoing physical, emotional, and practical barriers to the “long process” of recovery, sometimes exacerbated by rural contexts. However, we found that complex processes of active coping, finding meaning and acceptance, and caring for others contributed to their resilience. During this process, survivors sought and benefited from many kinds of support (e.g. family, friends, providers, formal structured peer programs like Burn Camp or support groups, and informal or formal online networks), and from providing support to others (informally or formally, often burn-injury-related), including telling their stories. However, not all interviewees used the same support systems or used them at the same stage of recovery. Some interviewees indicated that support systems need to vary throughout the recovery period.ConclusionsSurvivors could benefit from a flexible set of options for participating in peer support networks as both beneficiaries and providers of support. These options should ideally be accessible in different locations, through different mechanisms (e.g. camp, face-to-face, web-facilitated), and at different stages of recovery, even years after the injury. This is important especially for inpatients who may not be ready to benefit from structured peer support opportunities that could become difficult to identify or access once they leave the hospital.Applicability of Research to PracticeProviders can develop and communicate diverse support options and ensure that they are easily accessible to survivors, especially those in remote areas who may be years post-discharge.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.193
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 19 Nationwide Assessment of Fire and Burn Safety Education Programs and
           Evaluation Procedures
    • Authors: Radics-Johnson J; Ainsworth A, Kazemi E, et al.
      Abstract: IntroductionMany fire departments, burn foundations, and burn centers claim that they provide fire and burn prevention education in their communities, but how do these institutions measure the effectiveness of their programs'MethodsThrough a collaborative project between a statewide nonprofit burn foundation and a state university, a 37-question national survey was developed and distributed to evaluate fire and burn safety education programs and assessment procedures. Eligible participants in this study were at least 18 years of age and were referred by the nonprofit burn foundation as subject matter experts in fire and burn safety. The survey was administered online and distributed via email directly to identified subject matter experts or through mailing lists from national fire and burn prevention organizations. Questions included 1 consent question, 11 demographic questions, 3 institutional questions, 20 programmatic questions and 2 wrap-up questions.ResultsA total of 211 surveys were started and 135 surveys were completed in its entirety, representing 37 states throughout the US. There were 163 unique respondents; 2 respondents did not consent to participate in the study and 1 respondent was a repeat respondent. There were 28 respondents that did not complete all sections of the survey but were included for sections completed. The majority of the respondents were fire departments (n=124; 76.5%) that represented local municipalities (n=91; 56.2%) and provided fire prevention and life safety programs (n=156; 95.1%). The top 3 fire prevention programs offered included Smoke Alarm Education (n=137; 90.7%); Fire Escape Planning (n=131; 86.8%); and Fire Extinguishers (n=113; 74.8%). The majority of respondents stated that they evaluate the effectiveness of their programs (49.1%-52.8%). Number served (89.5%-91.5%) and injury-loss statistics (47.4%-63.8%) were the 2 most common methods of program effectiveness evaluation.ConclusionsAlthough the majority of the respondents of the survey stated that they evaluate the effective of their programs, the measurement tool most widely utilized is the number of people served. Simply counting the number of people served does not prove effectiveness of a program. More research needs to be done on how to effectively and accurately measure the effectiveness of fire and burn prevention programs.Applicability of Research to PracticeWith limited time and resources, fire and burn prevention educators need the right tools and messages to efficiently and effectively educate the public. Through this study, the statewide nonprofit burn foundation and the state university hopes to develop a measurement tool to help detect what actual behavior change occurs as a result of the fire and burn prevention education and training efforts.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.023
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 104 This is How We Do It: Rehabilitation Following the Use of an
           Autologous Cell Harvesting Device
    • Authors: Nakamura D; Richardson E, Craig C, et al.
      Abstract: IntroductionOur Burn Center participated in the compassionate use of an Autologous Cell Harvesting Device (ACHD) for the treatment of life-threatening burns in patients who lacked adequate split-thickness skin graft (STSG) donor sites (IDE 15945 NCT02992249). With the use of this new technology, traditional practices for post-operative burn therapy required modification to ensure positive surgical outcomes. Initially, after the ACHD procedure, we practiced conservative management. This was defined as strict bed-rest and no range of motion (ROM) for 7 days post-operatively. With further experience, we have updated our practices to involve more aggressive early physical and occupational therapy, and share our experiences below.MethodsMobility guidelines applied to patients with >20% TBSA grafted or >4000 cm2 grafted with the ACHD. Divided by anatomical region, the Post-Operative Mobility Guideline prescribes: Bed-rest until POD #4; Mobility with weight bearing as tolerated and functional ROM on POD #4; Full ROM on POD #6; Orthoses PRN for immobilizing joints and maintaining ROM.ResultsWe treated a total of 26 patients with 117 involved joints. Fifty percent of the patients were male, with a mean age of 25.5 ± 19.1 years, and a mean %TBSA of 51 ± 15.7%. (Refer to Table 1 for Healing Data). Anecdotally, use of the ACHD accelerated graft healing and maturation, resulting in less time for burn scar remodeling interventions. Patients initially exhibited skin and joint tightness from immobilization, however, tissue was easily manipulated to quickly regain ROM. Patients often transferred from the Burn ICU directly to inpatient rehabilitation, not requiring the same stabilization of graft healing as with STSG. Hypertrophic scarring was virtually eliminated. Pigmentation normalization was accelerated. There was less need for aggressive scar management modalities and techniques. Compression garment requirements were decreased.ConclusionsThe ACHD allows for quicker healing, less inflammation and edema, and less scarring than typically seen with STSG. We have seen optimal functional outcome. Further study of the ACHD with respect to cutaneous functional units, as well as its impact on inpatient rehabilitation length of stay, is needed.Applicability of Research to PracticeWith the introduction of new technologies, it is important to share experiences and knowledge gained with other burn care providers to ensure optimal outcomes for all burn patients.Table 1Healing DataDay 7Day 14Day 282 Month1 YearNumber of Evaluable Wounds Over Joints95109937983% Re-epithelialization≥ 80%87959696100≥ 95%45758794100*Graft loss at POD #6 = 12%*15% of wounds over joints required contracture release/reconstruction
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.105
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 319 Clinical Observations Using 3D Printed Hand and Finger Devices in
           Pediatric Burn Rehabilitation
    • Authors: Whitehead C; Begnaud E.
      Abstract: IntroductionThe recent increase in availability of easy to use, low cost 3D printers along with open-source designs has led to the proliferation of 3D printed hand and finger devices. Our purpose was to explore the role of these devices in pediatric burn rehabilitation.MethodsUtilizing existing designs, 3D models were selected and modified for patients with differing levels of amputations. The devices were fabricated with a 3D printer utilizing polylactic acid (PLA) and thermoplastic polyurethane (TPU) filaments allowing for rigid and flexible components. Case 1: Three year old male with amputation of all digits bilaterally. Bilateral wrist driven devices were fabricated with a simple 3-finger design providing flexion of the interphalangeal (IP) joints and metacarpal phalangeal (MCP) joints. Case 2: Eighteen year old male with amputation of right index finger at proximal phalanx. MCP actuated device was fabricated providing flexion of the IP joints. Case 3: Sixteen month old female with amputation of all digits bilaterally. Bilateral passive hands were fabricated for bi-manual play and added length.ResultsCase 1: A 3-finger design was chosen with a more simple design with reduced force needed for grasp. Patient did not actively engage devices and showed no interest, subject outgrew devices within two months. Case 2: Patient reported that he was pleased with device and used it to play piano. Patient had minimal changes in grip strength with and without device. He was unable to perform the nine-hole peg test without the device but completed it in 2 minutes and 13 seconds with device. Case 3: Passive hands were selected due to the patient’s age and level of cognition. Patient engaged in play activities with the devices and demonstrated an increase in activities previously not performed, including bringing hands to midline during play.ConclusionsOverall, devices generated from 3D printing can provide an appealing solution for those who have sustained a partial or complete loss of hand or fingers due to burn injury. Due to the likely presence of burn scar on the affected limb, the clinician must plan for the increased risk of break down when fitting the device. Opinions on aesthetics can vary greatly depending on the patient. Hand devices can look significantly larger than the unaffected limb due to the device fitting over the residual limb. When working with children, sizing of the device is important to account for growth of the arm and hand. Age and overall level of cognition should be considered in selection of passive versus body-powered device.Applicability of Research to PracticeThe use of 3D printed hand and finger devices in burn rehabilitation can provide an adjunct to traditional prosthetics including use for pre-prosthetic training and when traditional prosthetics might not be suitable.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.232
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 508 The Unique Challenge of Road Rash Injuries: A Systematic Literature
           Review and Case Series Addressing A Poorly Understood Mechanism of Burn
           Injury
    • Authors: Collier Z; Pham C, Yenikomshian H, et al.
      Abstract: IntroductionRoad rash or friction burns present unique challenges to burn providers. These injuries may be contaminated by environmental bacteria and foreign debris. Descriptions of road rash in the literature are heterogeneous, and the natural progression of friction injuries and their optimal treatments have not been fully described. We performed a systematic literature review to describe friction burn characteristics. We also performed a retrospective review to assess our experience with treating this unique type of burn.MethodsA systematic literature search was performed using PubMed, Scopus, and OvidSP MEDLINE databases as well as manually checking reference lists of relevant articles. The following keywords were used: road rash, friction burn, traumatic tattoo, and sheer injury. Case reports, reviews, and treadmill studies were excluded. We also performed an analysis of patients treated by our burn center for friction related injuries from January 1, 2017 to August 31, 2018. Demographics, interventions, and outcomes were evaluated for these patients.ResultsAfter abstract review of 22 pertinent articles, 7 were included for full-text analysis. After analysis, 4 articles, all with Level IV evidence, were reviewed and 184 patients were systematically evaluated. Friction burns occurred most often in young (22 years, mean) men (71%) because of motor vehicle accidents (78%). No studies recorded TBSA, but depth distribution was as follows: 29% partial-thickness, 49% full-thickness, and 31% had exposed vital structures (i.e. tendon, nerve, bone). For treatment, 36% received local wound care alone whereas 56% required surgery - 24% had local or free flap reconstructions. Similarly, our series of 9 patients were mostly young (21±17 years, mean) males (78%) involved in car accidents (100%) with a high incidence of full-thickness burns (44%), exposed structures (22%), and need-for-surgery (56%). We identified TBSA (6±6%), mean length of stay (14±15 days), wound infections rates (0%) and wound care regimens in 4 non-operative patients (2 silver sulfadiazine, 1 mupirocin, 1 silver-impregnated dressing).ConclusionsRoad rash injuries most commonly occur in young men due to car accidents, and, although most of these injuries comprise a small TBSA, nearly half are full-thickness and require surgery. Early bedside and/or operative debridement are necessary to prevent infection. Further prospective studies with long-term follow-up are indicated to better define the natural progression and optimal interventions for such injuries.Applicability of Research to PracticeRoad rash is a unique burn injury requiring emphasis on early, focused debridement of foreign debris with surgery or wound care to prevent infection and scarring.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.400
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 318 Efficacy of Whole Scar Ablative Fractional Carbon Dioxide Laser
           Treatment in Patients with Large Area of Burn Scar: A Prospective Cohort
           Study
    • Authors: Lv K; Liu H, Xiao S, et al.
      Abstract: IntroductionThe application of ablative fractional CO2 lasers (CO2-AFL) for small area burn scar management shows promising results. Few study has focused on comprehensive outcomes following CO2-AFL treatment for burn scar, to date no data on comprehensive outcomes of patients with large area scar (>30% TBSA) are available.MethodsA prospective study was initiated to analyze the efficacy of the whole scar AFL treatment for patients with large area of burn scar. Patients with extensive burn scars (>30% TBSA) were registered in our hospital from January 2016 to May 2018. According to the presence or absence of whole scar AFL treatment, patients were divided into two cohorts as laser group and control group. The questionnaire was followed up by one month after the last discharge during the observation period. Objective factors include the University of North Carolina “4P” Scar Scale (UNC4P) and Pittsburgh Sleep Quality Index (PSQI), Subjective parameters included 36-Item Short Form Health Survey(SF-36), Brief Version of Burn Specific Health Scale (BSHS-B), the Patient Scar Assessment Scale (POSAS-P) VAS itch score and Douleur Neuropathique 4 questions (DN4) were collected.ResultsDuring the study period, 19 patients (55.58±22.65% TBSA) were included in the laser group and 24 patients (58.95±16.46% TBSA) in the control group. The BSHS-B score (laser group vs. control group:113.89±33.62 vs. 92.54±31.88, p<0.05) and SF-36 score (laser group vs. control group:487.24±113.88 vs. 355.34±93.61, p<0.001) of laser group was higher than that of the control group; PSQI score (laser group vs. control group:8.0±5.29 vs. 12.5±5.32, p <0.01), POSAS-P score (laser group vs. control group:30.47±9.33 vs.43.65±7.93, p <0.001),VAS itch score (laser group vs. control group:4.15±1.77 vs.5.58±2.27, p <0.05), 5- D score (laser group vs. control group:11.73±4.00 vs.16.29±3.30, p <0.001), DN4 score (laser group vs. control group:3.41±2.4 vs.5.17±2.66, p <0.05) and UNC4P score (laser group vs. control group: 5.36±2.75 vs.7.33±2.08, p <0.05) of laser group significantly improved compared to control group.ConclusionsCompared with traditional treatment, whole scar AFL treatment can significantly reduce the itching of extensive burn scar patients, improve the sleep quality and scar appearance, and improve the life quality of scar patients.Applicability of Research to PracticeWhole scar treatment with the CO2-AFL provides a novel treatment modality for a holistic scar improvement, and the entire rehabilitative procedure may be enhanced and accelerated by this treatment, which may in turn lead to a faster re-integration in workplace and social life of burn victims and thus presents a milestone in burn patient management.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.231
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 221 Implementation of a Burn Champion Workgroup in a Mixed
           Medical-Surgical Pediatric Intensive Care Unit
    • Authors: Morgenstern S; Puett L, Ziegfeld S, et al.
      Abstract: IntroductionCritically burned children require specialized care by trained burn professional. Burns greater than 20% total body surface areas (TBSA) are relatively uncommon; therefore maintaining nursing competency in complex burn care is a challenge. In this large academic institution, the PICU nurse workforce varies in experience, with approximately 40% of nurses with less than 2 years of experience. A performance improvement project was implemented to address inadequate burn-specific education and inconsistent clinical care.MethodsTo improve nurses’ knowledge of pediatric burn care evidence-based interventions were implemented using the Plan Do Study Act cycles. In the first cycle, a hospital-wide burn nurse committee was formulated, inclusive of nurses from the emergency department, burn unit, and PICU. This committee developed interdisciplinary protocols that standardized clinical care and supported autonomous nursing practices. Performance metrics were established to monitor the quality and effectiveness of nursing care. Next, a new iteration of the PICU burn orientation class was developed to reflect new protocols and current evidence-based practice. Additionally, an advance burn concepts course was integrated into the required education in the PICU during the first year of hire. Ultimately, the third cycle saw the establishment of focused training for a small workgroup of burn nurse “champions” within the PICU. These nurses were used as resources at the bedside, provided one-on-one in-service training with policy implementation, as well as ongoing educational needs. This workgroup also allowed for the addition of a third burn concepts course to better enable nurses responding to the trauma bays to assist in early management of the pediatric burn patient. Monthly burn morbidity and mortality meetings proved to be an effective way to review burn cases and debrief the effectiveness of the interventions discussed above.ResultsAs a result of the implementation of the Burn Nurse Champion Workgroup, PICU nurses have demonstrated competence and expressed more confidence in the management of critical burn patients. Burn dressings are now nurse-driven with minimal assistance from Burn-team providers. Fluid resuscitation is now managed primarily by nursing, resulting in a decrease in the overall resuscitation volume critical burn patients receive within the first 48 hours of injury.ConclusionsImplementation of the a Burn Champion workgroup among nurses in a mixed medical-surgical ICU with a low volume of burns is an effective way to improve quality of care, provide just-in-time education, and continue to implement evidence-based initiatives and policies.Applicability of Research to PracticeThis method is replicable in similar settings
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.149
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 366 Humanized Skin Model in Severe Combined Immune Deficient Pigs
    • Authors: Singer A; Tuggle C, Ahrens A, et al.
      Abstract: IntroductionHypertrophic scarring after burns is common resulting in significant disfigurement and dysfunction. Further advances in understanding the pathobiology of scarring and the development of novel therapies aimed at reducing scarring are hindered by the lack of appropriate large animal models. Transplantation of human xenografts onto immune compromised mice is a powerful research tool for studying wound healing. However, differences in healing between humans and mice and their small size limits this model. Recently, a severe combined immune deficiency (SCID) pig was accidentally discovered. We determined whether human cadaver skin xenografts transplanted onto SCID pigs would survive and not be rejected.MethodsSplit thickness, meshed (1:1.5), cryopreserved human cadaver skin obtained from a skin bank was transplanted onto 10 partial thickness dermatome wounds in each of two normal domestic pigs and two SCID pigs. Autografts (n=2/animal) from the 4 animals were used as controls. Animals were followed for 4 weeks and periodic digital images and full thickness biopsies were obtained to monitor healing using H&E stains as well as T-cell specific CD3-antibodies. Human specific HLA antibodies were used to determine the origin of the transplanted skin in SCID pigs.ResultsIn normal pigs, all autografts were engrafted and healed with minimal if any inflammation and scarring. All human xenografts were rejected by the normal pigs within 5-11 days and associated with an intense T-cell inflammatory response. In contrast, both autografts and xenografts were engrafted and survived the 28-day study in the SCID pigs with minimal inflammation in only 1/20 xenografts and no gross scarring in any wounds. Human specific antibodies (HLA-ABC) confirmed the human source of the healed xenografts.ConclusionsThis study serves as proof-of-concept that human cadaver skin survives on SCID pigs for at least 28 days.Applicability of Research to PracticeFurther development of this model is ongoing to determine if human hypertrophic scars or keloids can be transplanted onto SCID pigs. We believe that a humanized scar model in pigs will be helpful in the development of novel therapies aimed at preventing or reducing hypertrophic scarring after burns.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.274
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 18 Fire Fighter Burn Injury Analysis using ABA NBR Data: Partnership to
           Improve Education and Outcomes
    • Authors: Kiley M; Flamm T, Phillips B, et al.
      Abstract: IntroductionBurn injuries are devastating for Fire Fighters and burn outcomes range from death to disability and removal from operational status. The objective was to develop a comprehensive Fire Fighter burn injury dataset, identify factors that contribute to improved outcomes for burn-injured Fire Fighters and utilize this dataset to develop prevention programs offering burn specific educational content.MethodsThe ABA and IAFF added new fields in the ABA National Burn Repository to collect specific data of the burn-injured Fire Fighter. A new field, Fire Fighter, was added in the occupation fields of the data dictionary. The Work-Related variable was included to differentiate data on the burn-injured Fire Fighter. This analysis was dependent on burn centers completing fields, submitting data to the NBR, and does not necessarily contain a representative sample. The data analysis represents the 2016 and 2017 ABA data collection of over 90 burn centers.ResultsThe report analysis is designed to raise awareness about burn-injured Fire Fighters and not to establish scientific fact. There is a small sample size of cases and considerations taken to ensure de-identification of the results. The study examined definitions and summary of findings to include analysis of admission type, record distribution by burn center, count of admissions by hospital bed size and type, cases submitted by age at admission, TBSA, cases by Baux score category, etiology, site of injury, burn injury by body location, inhalation injury, insurance category, length of stay and distribution of hospital charges. The results shared with the burn care community will enhance education and outcomes for the burn-injured Fire Fighter.ConclusionsThe research was executed using ABA NBR data, to focus on the burn-injured Fire Fighter and describe the burn injuries and associated outcomes of cases submitted. The key objectives of the research: develop a comprehensive dataset with Fire Fighter burn data; capture relevant Fire Fighter burn information and treatment protocols; understand the importance of transportation of burn-injured Fire Fighters to an ABA verified burn center; implement educational programs focused on prevention.Applicability of Research to PracticeIf the data collected on the burn-injured Fire Fighter can assist in decreased burn injuries, this is a return on investment. The primary intent is to create educational programs to prevent Fire Fighter burns from occurring and to provide an effective path of returning the Fire Fighter to operational status. Providing decision makers with evidence can have an immediate impact on reducing the incidence and treatment of Fire Fighter burns. This study is applicable to improving burn education and treatment programs for the general population.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.022
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 270 Long-Term Outcomes for Survivors of Childhood Burns; A Comparison of
           Honduran and US Samples
    • Authors: Kogosov A; Riobueno-Naylor A, Haile H, et al.
      Abstract: IntroductionThe Burn Outcome Questionnaire (BOQ5-18) is a validated instrument that assesses functioning of adolescents 5-18 recovering from burn injuries on twelve burn-specific physical and psychosocial domains. Limited research has focused on the use of the BOQ in developing countries. The current study evaluates the feasibility of using the BOQ5-18 in an outpatient clinic in Honduras and its usefulness for conducting a needs assessment.MethodsAs part of an outpatient burn clinic in Honduras, parents of patients seen in the clinic were asked to complete the Spanish version of the BOQ5-18. Domain scores of Honduran patients were compared to scores of patients from the Multi-Center Benchmarking Study (MCBS), a normative sample from the US. Because time since burn had been found to be a key variable in previous studies, the Honduran sample (n=28, with an average of 4.10 years since burn) was compared to the 50 MCBS subjects whose parents had completed the BOQ5-18 at Time 8 (T8), about 4 years since the burn. Chi-Square analyses were performed to examine differences in rates of risk on the 12 BOQ domains in the Honduran vs MCBS T8 subsample. Risk was defined as a BOQ5-18 domain score one standard deviation or more below the mean.ResultsTwenty-nine patients were seen in a Honduran clinic and 28 of them (96%) completed a BOQ5-18. Comparisons between the Honduran and US sample BOQ domain scores revealed only one significant difference. In the Honduran sample the rate of risk on the Itch scale was 17.9% vs. 0.0% in the US subsample (χ2 (2, 77) =13.48, p <.001).ConclusionsBOQs were obtained for 96% of the patients seen in a Honduran outreach clinic for children with burn injuries during a specified time, providing strong evidence that the use of this questionnaire in an outpatient burn clinic in Honduras is feasible. Overall, results showed that risk scores on the BOQ did not differ significantly on eleven of the twelve subscales, suggesting a similar pattern of BOQ risk and a general comparability of risk between the two sites. The significantly higher prevalence of risk on the Itch domain suggested that the BOQ could be useful in comparing patients from non-US locations to those in the US.Applicability of Research to PracticeThe BOQ5-18 could be a useful addition to routine follow-up care for youth with burn injuries in developing countries and could point to areas of greater risk in patients from these countries.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.192
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 421 Stage One Touch Burn Treatment for Pediatric Patients with DACC
           (Dialkylcarbamoyl Chloride)
    • Authors: Amjad I.
      Abstract: IntroductionSingle-stage one touch burn treatment for pediatric patients is a significant improvement over traditional treatments for young burn patients. Local wound and burn care in pediatric patients is problematic secondary to the amount of pain patients’ experience. Most burns that occur in the pediatric population are scald burns and second-degree burns which require local treatment including daily wound care. A 2% total body surface area burn increases the amount of pain a pediatric patient undergoes due to daily wound care and debridement. Further complicating daily wound care for pediatric burn patients is that often prescribed pain medication is poorly tolerated and suboptimal for daily debridement. Therefore, noting these issues treatment protocols had to be adjusted and changed in order to improve outcomes.MethodsPatients with burn injuries are usually seen in the emergency room or by a PCP in the first 24 hours for stabilization. The patient is then brought to the operating room within 72 hours sedated, debrided, and a complete dressing change is performed. Initially silver wound dressings were used in this population. A sterile moist silver dressing is applied covered with Kerlix and a cohesive dressing and changed weekly. Of concern with the pediatric patients is transcutaneous absorption of silver for large total body surface areas. Treatment of these patients has now progressed to use of DACC coated dressings. DACC is a hydrophobic fatty acid derivative that irreversible binds with bacteria rendering then inert. Since DACC is not a chemical agent it avoids the risk of systemic absorption and is safe for use in this population. DACC is applied with the use of a hydrogel and then wrapped in a similar manner and changed weekly.Results98% of patients had full closure of second-degree burns after one week. Burn areas of the fingers, chest, legs, and trunk were easily treated with this method. Facial burns proved to be slightly more problematic and required different more appropriate covering dressings.ConclusionsThis method of using the DACC coated dressing is cost-effective, safe for patients, and reduces the amount of pain medication required. Patient and family compliance was much higher and outcomes were much improved. This method has decreased the need for silver in burn wounds and alleviated concerns of transcutaneous absorption and toxicity. The introduction of DACC resulted in greater cost savings, anesthetic cosmetic results, and improved safety profile.Applicability of Research to PracticeThe one touch technique in pediatric patients with sedation or anesthesia eliminates pain and recurrent dressing changes. It is well tolerated in the pediatric population and compliance is easily attained, with excellent outcomes.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.318
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 60 Timing of Trauma Psychology Consultation and Hospital Length of Stay
           for Inpatient Burn Patients
    • Authors: Jackson B; Feldman M, Maher K.
      Abstract: IntroductionSurvivors of burn injuries frequently experience psychological distress, with short and long-term impacts on health and quality of life. Thus, psychologists have increasingly become integrated within burn centers. More recently, there is an increased focus of hospitals to reduce hospital length of stay (LOS), which is related to hospital-acquired conditions and increased cost. Research indicates psychological comorbidities are related to increased LOS. This is particularly relevant for burn patients with longer hospital recovery and may be exacerbated by acute psychological distress in the hospital. Delayed recognition of psychological comorbidities or acute psychological distress may decrease opportunity for intervention during hospital admission. The purpose of this research is examine whether timing of psychology consultation is related to hospital LOS to optimize burn patient care in hospital.MethodsThe current research examines a Level 1 Burn Center with a psychologist who saw patients an average of 3.6 visits per inpatient admission. A retrospective chart review examined whether timing of psychological consultation (M = 6.1 days, SD = 4.9) was related to hospital LOS (M = 15.0, SD = 10.3) in a sample of 59 burn patients with LOS greater than 4 days and less than 40 days between 2017 and 2018 (Age, M = 42.6, SD = 15.6). Consultation time was operationalized as number of days from admission to psychology consult. Additionally, previous research has shown the effect of consultation timing on LOS to be more accurate when measured as a proportion, hence a second variable measured consultation time as a proportion of LOS. Regression analyses assessed timing of consultation on patient LOS.ResultsAfter controlling for intubation and injury severity, both consultation timing (M = 4.7, SD = 5.75) and consultation timing as a proportion of LOS (M = .48, SD = .32) were significant predictors of hospital LOS (R2=.34, F(3,55) = 9.75, p<.0001; R2 =.32, F (3,55) = 8.83, p<.0001, respectively).ConclusionsPrevious literature has supported psychological interventions conducted in hospitals. However, few studies have explored the timing of consultation during burn hospitalization. The results suggest psychological consults conducted earlier in admission are related to decreased LOS.Applicability of Research to PracticeBecause the study is limited by the use of medical chart review and small sample size, RCT’s may further illuminate this relation. Results suggest earlier psychological screening and intervention may support a cost-effective method of reducing negative health impact and costs associated with LOS and emphasize the inclusion of psychology support on an interdisciplinary burn team.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.063
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 103 The Use of 3D Printed Devices to Address Scar Management of the Mouth,
           Nose, and Ear
    • Authors: Whitehead C; Musslewhite N.
      Abstract: IntroductionScar tissue surrounding the mouth, nose, and ears can create contractures that have long lasting effects on function. Current options to address these issues include high cost commercially available devices that lack customization or in-house solutions requiring a high degree of skill and time to fabricate. Our purpose was to develop a new model for fabrication of simple, cost effective scar management devices using 3D modeling and printing to provide customizable options with minimal fabrication time.MethodsUsing computer-aided design software, 3D models were designed to address the mouth, nose, and the external ear. A 3D printer was then used to fabricate these objects out of polylactic acid (PLA) filament. A static progressive mouth spreader was devised to maintain opening of the mouth to allow for proper feeding and airflow. Once assembled together with a screw and nut, one section slides along the length of the other section opening the mouth to provide a static stretch that can be serially adjusted. The design allows for a horizontal stretch of the mouth with a component designed to stretch the commissures vertically and maximize opening of the mouth. Several nasal stents were designed to be inserted into the nose to maintain the airway and prevent contracture of the nasal passage. Nasal stents are long, narrow devices with a widening in the middle and a hollow center allow for airflow with a wide base to prevent the entire device from entering the nasal cavity. These stents provide a static resistance and can be replaced with wider components to serially enlarge the opening. An ear cup was fabricated by creating a round protective shell that attaches to the head to protect the external ear. It protects and maintains dressings over the ear to prevent chondritis or avoid shearing of grafts.ResultsThese resultant devices are easy to fabricate and assemble, inexpensive, and durable. They can be used throughout the rehabilitation process and after surgical procedures. Printers can cost as little as $130, making them widely available. Factoring in labor and materials the estimated cost is $5 per mouth spreader, 50¢ per ear cup, and 10¢ per nasal stent.ConclusionsWhile these devices are not novel in burn rehabilitation, the method of design and fabrication provides multiple advantages. Fabrication through 3D printing allows for reliable mass production at low cost with easy modification of designs. Files can be easily shared electronically providing access for fabrication and use worldwide.Applicability of Research to PracticeFabrication through 3D printing provides devices that are simple to construct, require minimal hands on fabrication time, and are cost effective. The availability of these plans provide easy access and make them an effective tool to address scar management of the mouth, nose, and ears.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.104
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 462 Determination of Selenium, Copper, and Zinc Deficiency in Pediatric
           Burn Patients: Quality Improvement Project
    • Authors: Lee J; Herndon D, Finnerty C, et al.
      Abstract: IntroductionFollowing burns, micronutrient availability is of great concern as deficiencies can occur secondary to oxidative stress. Some micronutrients play a major role in the antioxidant response such as trace elements including selenium, copper, and zinc. In our pediatric burn unit, we routinely supplement zinc in all patients in order to support wound healing. We sought to determine whether these patients are deficient for other trace elements, including copper and selenium, and whether these elements should be routinely supplemented as well. As a quality improvement project, our first step was to determine the incidence of copper and selenium deficiencies and then to determine if they routinely need to be supplemented.MethodsMedical records were reviewed and all available serum selenium, copper, and zinc levels were collected from November 2016 to September 2018. If the levels were measured multiple times per patient, only the initial level was used. All patients received age appropriate daily zinc supplementation. No routine selenium or copper supplementation were given. Serum selenium, copper, and zinc concentrations were measured using inductively coupled plasma/mass spectrometry. Normal serum selenium concentrations range from 79 to 326 μg/L, with low normal defined as 79-89 μg/L. Normal serum copper concentrations are 72−166 μg/dL (40-170 μg/dL in children <9 months old), while low normal copper concentrations range from 72 to 82 μg/L. Normal serum zinc concentrations are from 56 to 134 μg/dL, with low normal defined as 56−66 μg/L.ResultsSerum selenium concentrations were measured 28 times in 24 patients; the four repeated measurements were excluded. Fourteen concentrations were below normal range (58%). Seven patients had low normal concentrations (29%), and 3 patients had normal levels (13%). Serum copper concentration was measured 23 times in 21 patients. Two repeated measurements were not used. Twelve patients had below normal range copper concentrations (57%), while 3 patients had low normal concentrations (14%) and 6 patients had normal values (29%). Serum zinc was measured 22 times in 21 patients. The single repeat was excluded. Nine patients were deficient for zinc (43%), while one patient had low normal concentrations of zinc (5%). Eleven patients had normal zinc concentrations (52%).ConclusionsSelenium, copper, and zinc deficiencies were common in our pediatric burn population. Testing for micronutrient deficiencies will now be routine in our burn unit prior to instituting supplementation of selenium, copper, and zinc.Applicability of Research to PracticeSelenium, copper, and zinc are important micronutrients in burn patients. By understanding the presence of trace element deficiencies, one can promptly provide supplementation.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.357
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 507 The Acute Development of Donor Site Squamous Cell Carcinoma: A Case
           Report and Review of the Literature
    • Authors: Miotke S; Mohr W.
      Abstract: IntroductionThe mainstay of burn reconstruction remains autografting. Donor site management centers on pain control, infection prevention, and scarring mitigation. Here we report a rare case of rapidly developing squamous cell carcinoma (SCC) at a split-thickness skin graft donor site.MethodsA 49-year-old man with no significant medical history sustained a 5% total body surface area (TBSA) full-thickness burn to the right upper arm, axilla, and trunk when his shirt sleeve caught fire at work. He underwent tangential excision and split-thickness skin grafting with VAC placement on post-burn day two. His right thigh donor site was dressed with an iodine-impregnated adhesive dressing. Graft loss necessitated return to the operating room on post-operative day 17 for re-excision and split-thickness skin grafting, again harvested from the right thigh. The donor site was dressed with a collagen-bound silicone dressing. On post-operative day 58/41 a lesion was noted on his right thigh donor site, presumed to be a cyst. On post-operative day 86/69, the lesion had grown to 7 millimeters. Excisional biopsy on post-operative day 129/112 revealed the lesion to be a well-differentiated squamous cell carcinoma with positive deep and peripheral margins. The patient returned for excision to negative margins 24 days later.ResultsSince 1948, seventeen prior cases of split-thickness skin graft donor site lesions have been reported in the literature. Fourteen of these (82%) were squamous cell carcinomas, with the remainder diagnosed as keratoacanthomas (KA) - a spontaneously regressing form of SCC, which rarely becomes invasive. Of the fourteen cases of SCC, thirteen (93%) were diagnosed within one year of graft harvest, and eleven (79%) were diagnosed within 6 months. Including our case, five of the cases involved burn patients.ConclusionsThe acute development of SCC at skin graft donor sites is a rare but serious phenomenon. Marjolin’s ulcers - the development of malignancies, commonly SCC, within chronic wounds - typically develop decades after injury. Trauma, including skin graft harvest, has been associated with the development of KAs, but, is not a typical risk factor for SCC. Given the diversity of autograft indications in reviewed literature, it seems unlikely that the burn itself contributed to the development of SCC. Rather, suspected contributing factors include an increased population of dividing cells provided by re-epithelialization in combination with decreased immune surveillance provided by the lack of lymphatic regeneration.Applicability of Research to PracticeThe rapid development of squamous cell carcinoma at a skin graft donor site represents a rare but serious possibility. Donor site diligence must be maintained post-operatively.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.399
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 269 Effectiveness of Social Skills Trainings for the Adult Burn Patients
           in Korea
    • Authors: Hwang S; Kim K, Baek S.
      Abstract: IntroductionBurn had the huge impact on the social reintegration after discharging from a hospital. Specially, burn scar with the revealed body such as face or arm could be damaged on the physical images, and people with burn felt anxiety due to social stigma upon them. After discharging from a hospital, people with burn experience need to prepare for these kinds of negative attention towards them. Social skills training is needed to help them to adjust to the community after the discharge from a hospital. With social skills training, people can increase the competence to socially adaptation and live in the community safely. This study aims to develop social skills training, implements this training, and evaluate the effectiveness of it.MethodsSocial skills training consisted of five topics including interpersonal relationships skills, self-acceptance, communication skills, coping skills toward negative social responses, and recovery of body image. The training was 4 times run with group activities, education, and practice of social skills including 8 sessions once per a week from 2017 to 2018. To evaluate the training, before and after the training, the self-reported survey and focus group interview were conducted. The survey used the Korean Version of Burn Specific Health Scale-Brief and self-esteem scale. The questions of focus group interview were the physical, psychological and social changes after the training. In addition, social validity and intervention validity were measured. Experimental design was used.ResultsProgram participants were 17 people with 14 males and 3 females. The average age of the participants was 44.7 years old and duration of burn was average 3.8 years. The score of the Korean Version of Burn Specific Health Scale-Brief was increased from 85.1 at the pretest to 86.2 at the posttest. The scale of self-esteem was increased from 26.8 the pretest to 27.8 at the posttest. As the results of focus group interview, participants accepted their changed body itself, revealed their burn body, and changed the body posture from being shrink to being dignified. In the psychological aspects, participants accepted themselves as they were, had the positive perspectives, increased emotional and verbal coping skills. The participants were having more social comfort, more willing to help other people with burn, having better relationship with family. Participants became not being aware of the other people’s attention toward them and understood why people looked at them.ConclusionsThe social skills training for people with burn is needed before the discharge from the hospital. The financial support is needed for the training as well as the training for social skills trainers.Applicability of Research to PracticeFindings may enlighten clinicians and researchers on practical models and strategies.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.191
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 363 Examination of Differences in Hypertrophic Scar Potential of Large,
           Full Thickness Wounds in Yorkshire Versus Duroc Swine
    • Authors: Smith Jr R; Carney B, Alkhalil A, et al.
      Abstract: IntroductionWound healing is a complex process with various outcomes, including repair back to normal skin, hypertrophic scar (HTS) and dyspigmented scar. Pigs serve as in vivo models to study wound healing as their skin shares many physiological similarities with humans. Two common models are Yorkshire (Yk) and Duroc (Dc) pigs. Yk pigs have been used to mimic normal wound healing while Dc pigs demonstrate abnormal wound healing (HTS/dyspigmented scar). The reason for this differential healing phenotype has not been extensively explored. Our goal was to examine if the same differences in healing held true in 16 square inch wounds.MethodsFull thickness excisional wounds (4x4 in) were made on the bilateral flanks of Dc and Yk pigs (n=8 scars each). Wounds were sampled and imaged weekly until 42 days post injury and then biweekly until day 98. At each check, an occupational therapist calculated a Vancouver Scar Scale (VSS) score. Re-epithelialization was analyzed using Image J software. H & E and Mason’s Trichrome stains were used to determine cellularity and collagen content of wound and scar tissue. Immunostaining for α-smooth muscle actin was used to determine blood vessel density in tissue.ResultsNormal Yk skin has a white phenotype that resembles Caucasian skin. It heals to a “port wine” HTS. Normal Dc skin has a red/brown phenotype that more closely resembles African American skin that heals to a dyspigmented, non-pliable HTS. Yk scars had a higher VSS score at all time points (n=8, p < 0.03). Yk wounds had a higher % re-epithelialization than Dc wounds at days 7, 14, 21, and 28, thus, these wounds closed faster. Tissue cellularity increased from baseline in both species at day 7 (n=8, p < 0.0002). In Yk tissue, cellularity was slightly above baseline at day 98, while Dc tissue remained more cellular than its baseline (p < 0.05). At day 98, Yk and Dc scars returned to similar collagen levels as healthy skin, although collagen disorganization was observed in both scars. Yk scar had increased blood vessel density at day 56.ConclusionsThis is the first work to show the outcomes of a full thickness excisional wound of this size on Yk pigs. The higher VSS score of Yk scar is mostly due to a higher vascularity score. Increased Yk scar blood vessel density at day 56 supports this finding. However, it is unexplained why Yk scar tissue begins to return to normal cellularity levels while Dc remains escalated.Applicability of Research to PracticeThese results suggest that there is a vast difference in how skin of differential pigmentation heals. Moving forward, when using an in vivo model to investigate new therapeutic treatments, it will be useful to include both pig types. This will provide insight into a treatment’s effectiveness on varying skin types.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.273
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 220 Supporting Burn Nurse Competencies with Education
    • Authors: Gauthier K; Wubbels A, Remington L, et al.
      Abstract: IntroductionIn 2017, a consensus-derived list of standardized competencies for burn nurses was published. To facilitate the implementation of these competencies, our American Burn Association verified (ABA) center created a curriculum with a combination of unit based and nationally recognized education tools focused on computer based modules. The goal was to provide foundational knowledge that helps burn nurses achieve these standardized competencies.MethodsUsing hospital policies and unit standards as a guide, an interdisciplinary group of burn nurses, physical therapists, social workers, pharmacists, respiratory therapists, and nutritionists created self-guided learning units. The institutional computer-based learning management system (LMS) was used as the repository for all elements of the learning units and all supporting materials. The LMS will be used by both preceptors and nurses in training.ResultsOur unit leadership successfully developed a curriculum that supports the standardized burn nurse competencies using a learning management system. The learning unit topics include the following: admission, fluid resuscitation, respiratory care, chemical burns, wound care, pain management, nutrition, psycho-social support, burn therapy, electronic medical record documentation, discharge planning and aftercare support. These units build on and expand material in the Total Burn Care text. Quizzes to assess learner knowledge have also been developed and are included with the LMS modulesConclusionsWe successfully created a curriculum using a learning management system to support to the ABA’s burn nursing competencies. The combination of internal and external resources will provide the foundational knowledge to help burn nurses achieve competency and ultimately obtain burn nursing certification. The next step will be to evaluate the effectiveness of the modules in knowledge acquisition by learnersApplicability of Research to PracticeA standardized curriculum for nursing burn care will help achieve the goal of developing a national burn nurse certification.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.148
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 17 A Health Equity Framework for Telemedicine at a Regional Burn Center
    • Authors: Ochtli C; Gibran N, Mandell S, et al.
      Abstract: IntroductionTelemedicine has the potential to mitigate multiple barriers to care and sources of health inequity. Additionally, telemedicine facilitates regionalized outpatient care and care for patients that would be disproportionately burdened by traditional clinic visits and consultations (e.g., long travel and visit times, direct and indirect costs). However, a framework for equitable burn telemedicine-based care delivery has not been reported. To fill this gap, we aimed to develop a framework that informs the planning and expansion of regional burn telemedicine centered on health equity.MethodsAn internationally validated framework used to classify barriers to care and sources of health inequity was identified. The framework has three dimensions: acceptability (e.g., fear and mistrust, cultural appropriateness), accessibility (e.g., structural barriers, service availability), and affordability (e.g., direct and indirect patient costs). Stakeholders of a regional burn center reached consensus on action priorities within each dimension. Subsequently, two satisfaction surveys were created in accordance with the dimensions and action priorities of the framework: one for patients eligible for burn telemedicine services, and a second for patients who engaged with burn telemedicine services. Lastly, proxy indicators were mapped to selected action priorities to facilitate assessment of program expansion and system performance and gaps.ResultsIn total, consensus was made on 21 action priorities (6 - acceptability, 10 - accessibility, 5 - affordability) that aim to reduce barriers to care and promote health inequity within the burn telemedicine system. 10 indicators that map to selected action priorities within each dimension were developed (see Table).ConclusionsThe proposed framework facilitates equitable planning and expansion of a regionalized burn telemedicine program. The burn telemedicine patient satisfaction surveys and indicators can be used to assess the program and monitor targeted quality improvement initiatives.Applicability of Research to PracticeThis framework and the corresponding indicators can be used to guide equitable burn telemedicine program expansion and assess system performance and gaps.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.021
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 102 The Impact of Discharge Contracture on Rates of Return to Work after
           Burn Injury
    • Authors: Pham T; Goldstein R, Carrougher G, et al.
      Abstract: IntroductionDespite many advances in burn care, the development of extremity contracture remains a common and vexing problem. Extremity contractures have been documented in up to one third of severely burned patients at discharge. However, little is known about the long-term impact of these contractures. The purpose of this study was to examine rates of return to work (RTW) in adults who develop extremity contractures during acute burn hospitalization.MethodsData was obtained data from the Burn Model Systems database from 1994–2003. All adult patients who were working prior to injury and identified those discharged with a contracture in one of the major extremity joints (shoulder, elbow, wrist, hip, knee and ankle) were included in the cohort. Contracture severity was classified according to mild, moderate and severe categories. Descriptive analyses and predictive modeling were performed to identify injury and patient factors associated with return to work at 6, 12, and 24 months.ResultsA total of 1,203 patient hospitalization records were identified. Of these, 415 (35%) had developed a contracture at discharge. The proportions of mild, moderate, and severe contractures were 9%, 12%, and 14% respectively. At 6 months post-discharge, 70% of patients without contracture had returned to work compared to 45% in patients with contractures (p<0.001), among 801 available records (33% missing data). Compared to 6 months post-discharge, RTW rates increased in patients with discharge contracture at 12 and 24 months, though remained significantly lower than in no-contracture patients (p<0.01). In multivariable analyses, female sex, non-Caucasian ethnicity, larger TBSA injury, alcohol abuse, number of in-hospital operations, amputation, and whether patients sustained in-hospital complications, were associated with a lower likelihood of RTW. In adjusted analyses, discharge contracture was associated with a lower probability of RTW at all 3 time points, although its impact significantly diminished at 24 months.ConclusionsThis study indicates an association between discharge contracture and a reduced rate of return to work at 6, 12 and 24 months after burn injury. Among many other identified patient, injury, and hospitalization factors that are barriers to RTW, the presence of a contracture at discharge adds a significant reintegration burden for burn patients.Applicability of Research to PracticeThis study improves our understanding of the impact of extremity contractures on return to work for burn patients.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.103
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 420 Improved Outpatient Follow Up Compliance of Patients Discharged to
           Long Term Care and Rehabilitation Facilities Achieved by Initiating
           Multidisciplinary Caregiver Communication upon Discharge
    • Authors: Frerk R; Cash J, Bernal N, et al.
      Abstract: IntroductionThe ABA requires that a verified burn center follow > 75% of patients who transition to outpatient burn care. Patients discharged from the burn service are given a clinic follow up appointment at the time of discharge. A PI project conducted to determine barriers for patients who did not follow up identified the group discharged to LTC/Rehab facilities as being at risk. A new communication process was initiated between the inpatient and outpatient teams to mitigate LTC/Rehab patients becoming lost to outpatient follow up.MethodsA email communication guideline was generated from the inpatient burn team to the outpatient burn clinic staff to facilitate compliance with outpatient follow up. The email included the name, brief overview, contact information at the new facility, transportation needs and accepting MD. These patients were also given a scheduled appointment at discharge.ResultsAfter implementation, 41 pts. were tracked post discharge to LTC/Rehab over 19 months, with a 19.5% loss to follow up rate. This was compared to the group identified in the original PI project of 54 pts. discharged to a LTC/Rehab over 21 months, with a 25.9% loss to follow up rate. Improved communication process resulted in a 6.4% improvement in follow up.ConclusionsWe found improved patients’ compliance with follow up appointments in the outpatient burn clinic post discharge from the hospital to LTC/rehab. We also found that when the Burn Clinic staff served as a resource to the LTC/Rehab facility by trouble shooting any areas of concern, fielding questions about wound care and identifying patients that might need to be seen earlier because of possible complications such as infection with the ultimate goal to improve patient outcomes.Applicability of Research to PracticeWe continue to email the outpatient clinic staff upon discharge of our inpatients to a LTC/rehab facility to increase capture of this pt. population. We also welcome feedback from staff in the outpatient setting as to any further areas of improvement. Future work will involve creating this process within the electronic medical record.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.317
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 59 Adverse Childhood Experiences (ACEs) in Burned Children and Impact on
           Burn Outcomes
    • Authors: Scieszinski L; Fassel M, Hosseini S, et al.
      Abstract: IntroductionAdverse childhood experiences (ACEs) are life events that occur before the age of 18. ACEs can lead to toxic stress and development of negative health behaviors and chronic diseases, especially for ≥4 ACEs. Current research primarily focuses on adult ACEs. The interaction between parent ACEs and their children’s subsequent health is poorly studied. This study assessed parent and children ACE exposure on presentation to our burn unit and their impact on burn recovery.MethodsChildren presenting to the burn unit were enrolled. Parents completed a self-report ACE-18 survey. ACE-18 questions included parent ACEs and child ACEs. Parents completed a strengths and needs survey and parent resiliency questionnaire. Follow-up surveys, including child depression screening (DSM-V) and Burn Outcome Questionnaire (BOQ), were completed at 1–3 months post-injury. Baseline analysis comparing the number of child ACEs (0 ACE and ≥1 ACE) or ages (<5 years and ≥5 years) were performed using SPSS 25.0. Significance was assumed at <0.05.ResultsSixty-nine children were enrolled. The average age was 5.3 ± 5.0 years (63.8% <5 years). Most were male (57%) and white (77%). The average total burn surface area was 4.1 ± 5.2%. Parents reported a mean of 2.4 ± 2.9 ACEs for themselves and 1.3 ± 1.8 ACEs for their children. A correlation was observed between parent ACE exposure and child ACE exposure (r = 0.57; p = 0.001). Children ≥5 years were more likely to have more ACEs (2.1 ± 2.6 vs. 0.8 ± 0.9; p = 0.0025) and parents with more ACEs (3.9 ± 3.9 vs. 1.5 ± 1.6; p = 0.0005). Average family needs were 2 ± 2.2; 46.4% reported 2 or more needs, including food insecurity (15.9%), housing insecurity (7.2%), and imprisonment of a household member (5.8%). Family needs were higher for families of children with ≥1 ACE (2.4 ± 2.4 vs. 1.3 ± 1.8; p = 0.042) and of children ≥5 years (3.0 vs. 1.4; p = 0.04). Older children were more likely to present with flame (p = 0.03) or flash burn-related injury (p = 0.006). Thirty-four participants (49.3%) completed follow up at 1–3 months post-injury (50.9 ± 22.5 days). Besides less male participants (47%), the follow-up population was comparable to the overall population. Most children presented with no signs of depression (88 to 100% depending on the questions), acceptable pain (86%) and were active (95%).ConclusionsOur data suggest that families of burned children and children themselves, especially those ≥5 years, present with an ACE burden and a significant number of needs and negative social determinants of health. The strength of ACE assessment may be in preventing future trauma and health consequences.Applicability of Research to PracticeThis understanding may enable health care providers to engage patient strengths and take into consideration their needs when devising a care plan to bring the child to a healthier life.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.062
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 316 Coverage of Bilateral Lower Extremity Burns with Autologous Homologous
           Skin Construct
    • Authors: Laun J; Weinstein B, Taylor L, et al.
      Abstract: IntroductionSplit-thickness skin grafts (STSG) are the standard of care for large burn wound coverage but can be limited by the amount of donor site skin available. STSGs are inherently partial thickness and do not have the ability to replace full-thickness skin leading to potentially increased risk of graft failure, scarring, contraction, and donor site morbidity. We evaluated the ability of a Autologous Homologous Skin Construct (AHSC) generated from a small full-thickness skin harvest, to cover large, full-thickness burn defects across both lower extremities in a patient with limited skin donor sites.MethodsA 45-year-old female was found unconscious at a house fire with 75% total body surface area (TBSA) mixed deep partial/full thickness burns to her upper/lower extremities, anterior/posterior torso, and inhalation injury. She developed septic shock, acute respiratory distress syndrome (ARDS), and acute kidney injury while in the Intensive Care Unit, also requiring cardiac resuscitation. She did not have enough donor site skin for complete burn wound coverage; therefore, AHSC was used for her lower extremity burns. An ~7x2cm fusiform full-thickness skin sample, including fat, was taken from uninjured abdominal skin and was processed into AHSC at an FDA-registered facility following current good tissue practices and returned to the provider two days following harvest.ResultsFollowing wound bed preparation and adequate debridement, AHSC was deployed on her bilateral lower extremities (30% TBSA) and STSG autograft covered her upper extremities as well as anterior/posterior torso over a staged timeframe. Full epithelialization of her lower extremities was noted by 6 weeks and she was discharged from the hospital at 8 weeks post-application. At 6 months, the regenerated skin covering her lower extremities demonstrated some pigmentation, scattered secondary skin appendages and full healing, requiring only a single application, no return to the operating room for revision and only local wound care.ConclusionsAHSC created from a full thickness donor piece of abdominal skin successfully regenerated a diffuse, intact skin replacement over bilateral lower extremities with some re-pigmentation noted within 2 months of post application. We plan on another biopsy at the 6 month timeframe.Applicability of Research to PracticeAHSC provides an opportunity to potentially treat and cover large surface area burns in patients who do not have sufficient unburned donor site skin for STSG harvesting.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.230
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 268 Incorporation of a Medical Spa in the Burn Center
    • Authors: Sherfeld K; Gabehart K, Roggy D, et al.
      Abstract: IntroductionIn November of 2005, we added a clinical esthetician to our multidisciplinary burn team and incorporated a Medical Spa into the Burn Center. Our esthetics team has provided therapeutic services to our burn patients that include microdermabrasion, chemical peels, camouflaging techniques, extractions of folliculitis, pre / post-operative facials, and laser services. The combination of these therapies expedites healing and aids in the reduction of post-operative edema.MethodsA review of the services provided to our burn patients by our Medical Spa was performed. The services provided by our estheticians are carefully documented, with photographs, and patient satisfaction recorded.ResultsBetween 2014 and 2017 esthetic therapies have been provided to 282 burn patients. These therapies included microdermabrasion (n=31+), pre-operative and post-operative facials including extractions for folliculitis (n=149+), camouflaging education sessions (n=41+), chemical peels (n=50+) and massage therapy (n=11+). The microdermabrasion treatments have been extremely successful in the treatment of folliculitis. The facial and chemical peel treatments have aided in reducing hyperpigmentation and hyperemia of scarring and increased the suppleness and pliability of hypertrophic scars. The camouflaging sessions have assisted our patients by increasing their body image, self-esteem, and confidence.ConclusionsOur Esthetics staff is a valuable addition to the burn team. They are capable of providing pre-operative and post-operative therapies that improve outcomes of reconstructive procedures; aid in the treatment of folliculitis; assist in scar management; and, most importantly, provide services to improve the burn survivors’ body image and self-confidence.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.190
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 506 A Burn Center’s Four Year Experience with a Cerium Nitrate &
           Silver Sulfadiazine Burn Cream
    • Authors: Garg G; McLawhorn M, Moffatt L, et al.
      Abstract: IntroductionMorbidity from burn wound infection & sepsis remains high, but can be improved by early excision & grafting. However, certain situations preclude early surgery. In these cases, topical agents allow for staged excision. The combination of cerium nitrate & silver sulfadiazine (Cerium) is an inexpensive burn cream with broad antibacterial activity. It also forms an eschar over the wound that may promote reepithelialization. Methemoglobinemia (MetHba), an oft-cited side effect, is rare, but the compound is infrequently used worldwide. This is a retrospective cohort study investigating the effects of Cerium at a regional burn center.MethodsAfter IRB approval, patients admitted between 7/1/2014 & 7/1/2018 were screened to determine if they received Cerium. Data including demographics, burn injury & management, laboratory values & cerium application were extracted. Primary endpoints were time to surgery of Cerium-treated burns, reepithlialization & incidence of MetHba & its treatment.ResultsOf the 142 patients meeting inclusion criteria, the mean age was 56.3 & the majority were black (46%) males (67%). The most common etiologies were flame (43%), contact (25%) & scald (18%). Smoking was prevalent (28.5%). Mean TBSA was 9.9% with mean adjusted Baux score of 67.9 & APACHE II score of 10.8. 64.3% were admitted to the ICU & 10.7% had inhalation injury. Time to Cerium application was 1.67 days with 15.5 total doses received. Total TBSA treated with Cerium was 6.1% (4.5% full thickness, 1.6% partial thickness). Time to any surgery was 2.6 days whereas the time to surgery for areas treated with Cerium was 4.8 days. 10.7% of patients had treated wounds smaller than presentation at time of surgery. The mean pre-Cerium methemoglobin (MetHb) value was 1.2, while checks 12-36 h & 48-72 h post first application were 1.2 & 1.4, respectively. 9.8% developed MetHba levels >2.5%. All patients except 1 were asymptomatic. The symptomatic patient became hypoxic with MetHb of 9.4%, required reintubation, & was treated with Methylene Blue.ConclusionsAt our center, Cerium is a well-tolerated medication with a minimal side-effect profile. Only one patient (0.7%) developed clinically significant MetHba requiring intervention. Reintubation in this patient was multifactorial as he had been extubated the same day & required frequent suctioning for copious, thick secretions, in addition to MetHba. Previous reports have described patients tolerating MetHb levels up to 31.8% without intubation. It can successfully be used to temporize burn wound excision & grafting, with our data supporting reepithelialization. Future work will study Cerium prospectively.Applicability of Research to PracticeCerium cream is a topical dressing with few side effects which allows delayed burn excision & may improve tissue salvage.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.398
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 362 Non-Severe Burn Injury has a Long-Term Impact on Immune Function in
           Pediatric Patients
    • Authors: Fear V; Fear M, Wood F.
      Abstract: IntroductionBurns are a significant cause of morbidity and mortality worldwide, and while the acute impact of burns on immune function has been well characterised, the long-term impacts are only more recently coming to light. Epidemiological evidence of long-term effects of burn injury include increased mortality risk, increased susceptibility to respiratory infections and increased cancer risk. The mechanisms underpinning this long-term morbidity are yet to be elucidated. However, we hypothesise that disruption to immune function is sustained after burn injury and is key to the long-term morbidity observed in burn patients.MethodsTo investigate the long-term changes in immune function we have collected plasma and peripheral blood mononuclear cells (PBMCs) from pediatric patients that had a non-severe burn injury between the ages of 1-3 years at least 2 years after their burn injury. These samples were compared to a matched age/gender population that had no burn injury. Using multiplex assay for cytokine and circulating antibody levels as well as mass cytometry to profile cell types we have analysed differences in the circulating immune components in patients and non-burn injured controls.ResultsWe have identified significant changes in the levels of circulating cytokines in patients when compared to age and gender matched non-injured control samples. We have also identified significant changes in circulating antibodies to vaccination antigens in the burn patient cohort as well as changes in the PBMC profiles in burn patients at least 2 years after their injury.ConclusionsThe data provides evidence of long-term changes to circulating immune cells and markers, suggesting non-severe burn injury has a sustained impact on immune function in the pediatric burn injured populationApplicability of Research to PracticeUnderstanding the impact of burn injury on immune function will facilitate change to practice to promote better recovery of immunity after burn injury, reducing the long-term morbidity in pediatric patients.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.272
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 100 Post-Acute Care Setting is Associated with Employment After Severe
           Burn Injury
    • Authors: Espinoza L; Simko L, Goldstein R, et al.
      Abstract: IntroductionDespite the growing use of post-acute care in the United States, few studies have examined differences in long-term outcomes by specific post-acute care setting. Adult burn survivors represent a population that exhibit impaired long-term outcomes and often require post-acute care. Currently, limited data exist regarding which care setting provides the most benefit to this population. The purpose of this study is to examine differences in long-term employment outcomes of adult burn survivors by post-acute care setting.MethodsData was obtained from the Burn Model System National Database between 1994 and 2016. Adult burn survivors who were alive at discharge and required post-acute care following acute care discharge were included. The population was divided into two groups - those who received post-acute care at an inpatient rehabilitation facility (IRF Group) and those who received post-acute care at a skilled nursing facility, long-term care hospital, or other extended care facility (Other Rehab Group). Employment status was assessed at 12 months post injury. Propensity score matching (controlling for 16 demographic and clinical variables) and logistic regression were used to determine the impact of post-acute care setting on employment status.ResultsThis study included a total of 695 burn survivors (447 in the IRF Group; 248 in the Other Rehab Group). Individuals in the IRF Group had larger burns and were more likely to have an inhalation injury and to have undergone an amputation. Additional demographic and clinical characteristics can be found in Table 1. Logistic regression analysis using propensity score matching found the IRF Group had over 9 times increased odds of being employed at 12 months post-injury compared to the Other Rehab Group (p=0.046).ConclusionsInpatient rehabilitation facilities provided a long-term benefit for burn survivors in terms of regaining employment when compared to other acute care settings such as skilled nursing facilities, long-term care hospitals, and other extended care facilities.Applicability of Research to PracticeGiven the current lack of evidence-based guidelines on post-acute care decisions, the results of this study shed light on the potential benefits of the intensive services provided at inpatient rehabilitation facilities in this population.Demographic and clinical characteristics of the study populationVariableOther RehabIRFp-valueNumber of participants248447Age, mean years (SD)51.2 (18.5)44.8 (16.1)<0.01Male, No. (%)170 (68.5)312 (93.8)0.73White, No. (%)213 (93.8)360 (93.8)0.97Hispanic or Latino/a, No. (%)10 (4.5)60 (14.3)<0.01Employed at time of injury, No. (%)75 (32.3)264 (59.5)<0.01TBSA burned, mean (SD)16.3 (14.9)34.3 (21.2)<0.01Burn etiology, No. (5)<0.01Fire/flame151 (67.4)343 (78.3)Scald33 (14.7)26 (5.9)Grease6 (2.7)13 (3.0)Electricity3 (1.3)28 (6.4)Other31 (13.8)28 (6.4)
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.102
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 461 The Effect of Pre-Existing Seizure Disorders on Mortality, Intensive
           Care Unit and Hospital Length of Stay Following Burn Injury
    • Authors: Atwell K; Bartley C, Cairns B, et al.
      Abstract: IntroductionSeizures are electrical disorders of the central nervous system in which brain activity becomes abnormal, causing periods of unusual behavior, sensations, and sometimes loss of awareness and consciousness. This event increases an individual’s risk for burn injury. Studies have shown that patients with epilepsy have a higher incidence of burn injury; however, there are limited studies that examine the association of pre-existing seizure disorders (PSD) on burn mortality and other outcomes.MethodsThis is a retrospective study of patients admitted a regional burn center from 2002-2012 and entered in the burn registry. Variables analyzed include basic demographics, total body surface area (TBSA) of burn, burn etiology, presence of inhalation injury, Charlson comorbidity index, presence or absence of preexisting seizure disorders and intensive care unit (ICU) and hospital length of stay (LOS) and mortality. Univariate analysis was used to describe patient characteristics from the study group. Bivariate analysis and multivariate logistic regression were performed to analyze PSD impact on burn mortality, hospital and ICU LOS.Results7,640 adult and pediatric patients met the inclusion criteria for study period. Of this population, 1.31% (n= 100) patients had a pre-existing seizure disorder (PSD). There was no difference in burn mortality rate between patients with PSD compared to those without pre-existing seizure disorder (NSD) after controlling for other co-variates (OR =2.07, 95% CI=0.80-5.37). The multivariate logistic regression to estimate odds ratio showed that patients with PSD have an increased hospital LOS twice the mean LOS compared to those with NSD, (OR = 2.0, 95% CI=1.30-3.07).ConclusionsPatients with PSD have a significantly higher hospital LOS without increase in burn mortality. Appropriate seizure disorder management is mandatory in reducing burn injury and decreasing the costs associated with increased hospital length of stay.Applicability of Research to Practice: Highly Applicable
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.356
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 58 CAGE Substance use Scores and Trajectories Over Time Following Burn
           Injury: A Burn Model System National Database Study
    • Authors: Grant G; Wolfe A, Thorpe C, et al.
      Abstract: IntroductionThe self-reported CAGE substance use tool (Cut down, Annoyed, Guilty, and Eye-opener) screens for potential problems with alcohol or drug use. This study aims to examine the prevalence of substance use in the Burn Model System (BMS) National Database adult population by reviewing CAGE substance use scores and trajectories over time following burn injury.MethodsIndividuals 18 years of age or older, alive at discharge (DC), and with 2 complete self-reported CAGE questionnaires (at DC and at least one follow-up time point at 6, 12, or 24 months post-injury) were included. Enrollment criteria includes individuals with ≥ 10% Total Body Surface Area (TBSA) burned (age ≥ 65 years) or 20% TBSA burned (age 18–64 years) and/or burns to critical areas. CAGE questions at DC assessed a patient’s history of alcohol or drug use in the last 12 months. Demographic and clinical characteristics of those who reported positive CAGE scores (total score of ≥ 2) and those who reported negative CAGE scores (total score of 0 or 1) for either alcohol or drug use were compared. Changes in CAGE scores between discharge and follow-up were also analyzed using paired t-tests.ResultsA total of 408 adult burn survivors were included in the analysis. Individuals reporting positive CAGE scores for either alcohol or drug use at DC were 70% male with a mean age of 42.9 years (SD=16.4, range=18.5) and mean burn size of 21% TBSA burned. Individuals reporting negative CAGE scores at DC were 83% male with a mean age of 47.6 years (SD=13.8, range=18.7) and mean burn size of 19% TBSA burned. Statistically significant differences in age and gender were found (p < 0.01). TBSA burned did not differ significantly between the two populations. Approximately 1 out of 5 people reported a positive CAGE score (18%) at time of DC and about half of those (47%) reported positive CAGE scores at follow-up. Of those who reported negative CAGE scores at DC, 10% reported a positive CAGE score at follow-up.ConclusionsSubstance use at DC and follow-up in this sample is potentially an important concern. These CAGE scores reflect the need for health care providers to counsel patients about substance use and the need to screen burn survivors for substance use at later follow-ups.Applicability of Research to PracticeFurther investigation is needed to understand the extent of substance use in the burn survivor population. Increased efforts for more effective substance use treatment appropriate for burn survivors should be an important focus of intervention.Number of individuals with +/- CAGE Substance Use scores at discharge and follow-upCAGE + at Discharge (N=74)CAGE - at Discharge (N=334)p-valueCAGE + at Follow-Up, No. (%)35 (47.3)34 (10.2)0.002CAGE - at Follow-Up, No. (%)39 (52.7)300 (89.8)0.000
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.061
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 419 Uptake of PHMB in a BNC-Based Wound Dressing
    • Authors: Holzer J; Tuca A, Bernardelli de Mattos I, et al.
      Abstract: IntroductionWith the rise of antimicrobial resistance, other methods of preventing and fighting infections must be considered. Burn patients are especially prone to wound infections. The loading of bacterial nanocellulose (BNC) with antiseptics has already been successfully performed but unfortunately, the described procedure is time-consuming and thus not applicable in a clinical emergency setting. Therefore, a clinically feasible approach was established.MethodsSheets of BNC-based wound dressings were placed into antiseptic solutions containing PHMB (Prontosan® and LAVANID® 2) and were left to soak for up to two hours. At different time points, punch biopsies were taken and analysed for their concentration of PHMB.ResultsClinically relevant concentrations of PHMB were already achieved in the BNC-based wound dressing after 30 minutes. The 30-minute PHMB uptake for Prontosan® and LAVANID® 2 resulted in concentrations of 0.05 % and 0.019 %, respectively. The uptake from Prontosan® or LAVANID® 2 reached 95 % and 76 %, respectively, of the possible maximum.ConclusionsThis experiment showed that the loading of BNC-based wound dressings with PHMB-containing antiseptics was achieved by a simple and time-saving procedure. Studies have already shown that a PHMB concentration as low as 0.001 % inhibits all bacterial growth, indicating that the concentrations of PHMB in the BNC-based wound dressings after 30 minutes are far higher than the minimal inhibitory concentration.Applicability of Research to PracticeThis procedure is applicable in every clinical setting, where an antiseptic solution of PHMB, a BNC-based wound dressing and a metal kidney dish is available. With no special equipment needed no training is required to produce a PHMB loaded BNC-based wound dressing.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.316
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 16 A Framework for a Successful Pressure Injury Prevention Program in a
           Regional Burn Center
    • Authors: Cox L; Kesey J, Griswold J.
      Abstract: IntroductionBurn-injured patients are inherently at-risk for pressure injuries. Little evidence exists regarding pressure ulcer prevention practices for burn centers. Our verified burn center sought to decrease the incidence of hospital-acquired pressure injury (HAPI) by reducing device and positioning related pressure injuries. A key part of our plan includes education for all staff.MethodsWe conducted the study at a verified regional burn center serving adult and pediatric populations. While on our journey to Magnet designation, we tracked National Database of Nursing Quality Indicators (NDNQI) data quarterly. Preliminary data indicated our rate of HAPI was above the national benchmark. We currently employ interventions such as turning every 2 hours, padding of bony prominences, use of pressure reducing or air circulating beds, proper skin care, nutritional assessment, measures that decrease length of stay, use of the Braden Scale to assess risk, and early mobilization. In addition to, we elevated some of these practices by frequent reposition of catheter securement and other invasive devices to prevent mucosal injury, elimination of supine laying in turning schedule, and improved nutritional management. The risk reduction strategy includes an improved method for securing nasogastric tubes, moisture management of wounds, standardizing heel protection, padding securement ties for endotracheal tubes, restricted use of touch fasteners on all ace bandages, regulating c-collar care, directing splint checks and addition of a stretch bandage training protocol. We collected data from monthly surveys reported to NDNQI for a total of 8 quarters. All HAPIs are reported to NDNQI specifically as the total number of HAPIs, number of patients with a HAPI, and HAPIs identified per patient.ResultsOur findings demonstrate a decrease in the overall number of HAPIs occurring in our unit since the introduction of our prevention program (p= 0.037). The number of patients with HAPIs and the number of HAPIs adjusted for unit census also dropped (p= 0.021 and p= 0.040 respectively). In addition to the decrease in the number of overall HAPIs, we have seen historically low incidence of HAPI.ConclusionsThe burn center has experienced a dramatic decline in the incidence of hospital-acquired pressure injury due to prevention initiatives and risk reduction strategies. Burn centers should adopt programs to prevent hospital-acquired harm rather than maintain a reactive approach. Involving bedside nursing staff increases effectiveness of programs.Applicability of Research to PracticeResearch is ongoing to evaluate the impact of various prevention strategies for hospital-acquired pressure injury specific to the burn population. A coalescence of practices is needed to establish industry standards of care.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.020
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 315 The Use of High Frequency Ultrasound to Monitor Treatment of
           Hypertrophic Burn Scars with Fractionated Ablative CO2 Laser Therapy
    • Authors: George R; Siordia H, Buhler J, et al.
      Abstract: IntroductionTreatment of hypertrophic burn scars using fractionated ablative CO2 laser is increasingly adopted by burn centers and burn scar treatment facilities. While high level, definitive evidence for this type of therapy is still lacking, fractionated ablative CO2 laser is purported to improve the symptoms of hypertrophic scarring by decreasing scar stiffness, irregularity and thickness. Several objective measures are available as research tools to monitor treatment progression though few of these metrics are commonly used in a non-research setting. In this study, we seek to demonstrate that ultrasound scar thickness can be feasibly integrated into the clinical treatment of hypertrophic burn scars to monitor patient response.MethodsAs part of a process improvement effort, patients undergoing CO2 laser therapy were prospectively followed using ultrasound determination of scar depth. A deep FX handpiece of the CO2 laser was used for the therapy. One area of a symptomatic hypertrophic burn scar was selected on each patient for evaluation by ultrasound. Scar thickness was measured prior to the initial treatment as well as prior to each subsequent treatment.ResultsHypertrophic burn scars with age of injury from less than 1 year to 7 years (mean 646 days) were prospectively studied on 11 patients. A total of 15 sessions were performed during the study period (mean 1.4 sessions/patient). One patient underwent three treatments after initial evaluation; two patients underwent two treatments; and eight patients underwent one treatment. Scar thickness decrease of 25% (95% CI, 7.3%-42.5%) and 30% after one and two treatments were noted, respectively. A correlation was noted between initial scar thickness and percentage decrease, where a 48% decrease in scar thickness can be expected for every 1mm of initial scar depth.ConclusionsCO2 laser therapy is fast becoming a standard in the treatment of hypertrophic burn scars, though questions remain regarding its efficacy. Objective measurements to follow patients’ response to therapy will be important to the patient and his/her provider, but also to third-party payers in deciding whether additional treatment sessions are medically necessary. In this limited study, the use of CO2 laser therapy demonstrated decreases in scar thickness. Data from a randomized, controlled study is still needed to demonstrate this effect, though continuation of this uncontrolled effort will still add evidence to support CO2 laser use in each individual patient.Applicability of Research to PracticeThe use of an ultrasound to measure scar thickness after treatment with CO2 laser therapy is reproducible, readily available and can feasibly be integrated into a laser clinic to monitor patient response.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.229
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 266 Developing a Screening Tool to Assess Acute Stress Disorder in Burn
           Patients
    • Authors: Alem P; Klecka E, Rynkowska E, et al.
      Abstract: IntroductionAcute stress disorder occurs after an individual is exposed to one or more traumatic events. Symptoms can include negative mood, dissociation, avoidance and anxiety/hyperarousal, which can occur from three days to one month post exposure. Acute Stress Disorder (ASD) affects 21–23.6% of adults and is more often diagnosed in women (23%) than men (8%). After being diagnosed with ASD, 57% of men and 92% of women developed post-traumatic stress disorder (PTSD) within six months. Patients with severe burn injuries receive lengthy intensive physical rehabilitation; a focus on the mental health component is often suboptimal. One study showed that 21% of patients presented with symptoms of PTSD. According to the literature, between 30% and 50% of individuals sustaining a burn injury have a pre-existing psychiatric comorbidity making them more vulnerable to self-harm or suicide post burn.MethodsOur burn center does not currently have an established process to screen for ASD. A literature search was conducted to gain a detailed understanding of the scope of this problem, and to develop a process that could be easily administered by the nursing staff to provide early intervention.ResultsTo initially screen patients, the Acute Stress Disorder Scale (ASDS) was selected. The tool is easy to administer and identifies key risk factors of ASD, which include: patients with less than a high school education, ethnic minorities, burn injury, history of domestic violence and previous suicidal ideation. For patients who have a positive ASDS score of 27 or greater, the National Stressful Events Survey Acute Stress Disorder Short Scale (NSESSS) is administered, and a psychiatric referral is initiated. Although early intervention is best, due to severity of their injuries patients are not screened until they are placed on stepdown protocols. Patients who do not initially receive positive ASDS scores are screened weekly until discharge. Once discharged, patients with positive ASDS scores would be counseled and supplied with a list of psychiatric resources/facilities for follow-up.ConclusionsEarly screening post-injury to identify ASD is critical to the management of traumatic stress disorders. Implementing a screening tool for assessment of patients sustaining a burn injury will allow for earlier identification of individuals and allow for earlier interventions.Applicability of Research to PracticeScreening tools when implemented as part of standard nursing practice ensures patients receive physical and mental health assessments, resulting in earlier interventions for a more comprehensive recovery.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.189
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 219 Quantifying the Effects of Wound Healing Risk and Potential on
           Clinical Measurements and Outcomes of Severely Burned Patients: A “Big
           Data” Approach
    • Authors: Liu N; Shingleton S, Fenrich C, et al.
      Abstract: IntroductionThe goal of this study was to quantify the effects of wound healing risk and potential on clinical measurements and outcomes of severely burned patients, with the hope of providing more insight on factors that affect wound healing.MethodsThis retrospective study employed a “big data” approach to analysis and involved patients who had at least 10% TBSA burned and three burn mappings each. The variable θ was used to define a practical wound healing threshold to categorize patients and represented risk to wounds. “Low-risk” patients denoted those patients who were less at risk (open wound size ≤ θ) and had more healing potential, whereas “high-risk” patients denoted those patients who were more at risk (open wound size > θ) and had less healing potential. 100 sub analyses were performed by 1) varying a threshold (θ) from 100% to 1% in decrements of 1%, 2) grouping all patients as either “low-risk” or “high-risk” for each θ, and 3) comparing all variables and outcomes between the two groups for each θ. Plots and tables were obtained.ResultsA total of 303 patients were included in the analysis. Mean age and weight were 45 ± 19 years and 87 ± 20 kg, respectively. Mean TBSA burned was 30 ± 18%, with a full-thickness burn of 11 ± 18%. Average crystalloid volumes were 4.25 ± 2.27 mL/kg/TBSA in the first 24 hours. Importantly, for high-risk patients, decreasing their risk θ was matched by increasing PaO2-FiO2 ratio, platelet count, Glasgow coma score (GCS), and MAP. Decreasing their risk θ was also matched by decreasing creatinine, bilirubin, lactate, blood, estimated blood loss, and 24-hr and total fluid volumes. As expected, for low-risk patients, clinical measurements were more stable, despite decreasing or increasing θ. At a θ of 80%, statistical tests indicated much disparity between high-risk and low-risk patients for TBSA burned, full thickness burn, bilirubin (1.66 ± 1.16 mg/dL versus 0.83 ± 0.65 mg/dL, p=0.005), GCS (7 ± 2 versus 12 ± 3%, p<0.001), MAP (42 ± 22 mm Hg versus 59 ± 22 mm Hg, p=0.004), 24-hr blood, estimated blood loss, 24-hr fluid, total fluid, and ICU length of stay (81 ± 113 days versus 24 ± 27 days, p=0.002). These differences were all statistically significant and remained significant down to θ = 10%.ConclusionsWound healing risk and potential may be assessed by many different clinical measurements and outcomes and has many implications on multi-organ function. Future work will be needed to further explain and understand these effects, in order to facilitate development of new predictive models for wound healing.Applicability of Research to PracticeBurn wound progression may be assessed by many different clinical measurements and outcomes, which may be incorporated into wound management strategies in order to enhance or stratify wound care.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.147
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 361 Bioactive Nanoparticles for Improved Wound Healing
    • Authors: Bulutoglu B; Devalliere J, Deng S, et al.
      Abstract: IntroductionWound healing involves interactions among different cell types mediated by chemokines and cytokines. Currently, the standard of care involves the topical delivery or injection of growth factors and other chemokines. These treatment options may require multiple applications since purified growth factors are short-lived in the proteolytic wound environment. Our group developed a nanoparticle delivery platform consisting of fusion proteins of elastin-like peptides (ELPs), derived from human tropoelastin, with therapeutic factors. These proteins provide sustained delivery and protect therapeutic factors from proteolytic degradation.MethodsWe made fusions of different ELP platforms and therapeutic proteins at the DNA level followed by recombinant protein expression and purification. Purified therapeutic proteins were tested for biological activity and stability via in vitro cell cultures (e.g. proliferation and cell viability assays) and in vivo wound healing models. In addition, therapeutic ELP particles were incorporated into commercially available tissue scaffolds and tested in vitro and in vivo.ResultsTherapeutic ELP fusions targeting various aspects of the healing cascade were constructed: keratinocyte growth factor (KGF)-ELP, targeting the epidermis, stromal-derived growth factor 1 (SDF1)-ELP, targeting the dermis, and peptide cathelicidin (LL37)-ELP, providing anti-microbial activity. KGF-ELP was incorporated into a skin graft and sustained KGF release over 2 weeks was obtained. KGF responsive epithelial cell line A431 incubated with the KGF-ELP, released from the skin substitute, proliferated faster, indicating the intactness of KGF biological functionality. In addition, KGF-ELP incorporated tissue scaffolds were tested in an in vivo mouse model demonstrating the beneficial effects of ELP - growth factor fusion platform. In parallel, we recently developed another ELP platform forming micelles in response to temperature changes. SDF1 and LL37 were fused to this construct for co-delivery and currently this platform is being tested for biological activity and efficacy.ConclusionsThese studies demonstrated that ELPs can be employed as smart biomaterials for drug delivery. They protect the therapeutic cargo from degradation while maintaining their biological activity in vitro and in vivo.Applicability of Research to PracticeThis technology will provide economical, practical and therapeutic benefits in burn wound healing and will facilitate sustained availability of different therapeutics at the wound site. Moreover, this research is expected to yield a new generation of skin equivalents that is more effective than the systems currently available.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.271
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 505 A Five-Year Review of Pavement Burns from a Desert Burn Center
    • Authors: Vega Jr J; Chestovich P, Saquib S.
      Abstract: IntroductionThe majority of burn related injuries are attributed to flame burns and scald burns. However, in the American Southwest and other hot climates with daily temperatures over 100 F, pavement burns also account for significant burn related injuries. Pavements absorb radiant energy and are hotter than ambient temperatures, and can be a significant source of burns.MethodsWe performed a 5-year retrospective review of our burn center registry (2013- 2017). We obtained atmospheric temperature data from the National Centers for Environmental Information section of NOAA. The daily maximum and average temperatures for was obtained for all five years. We plotted the temperature values for each of the pavement burn related injuries that were admitted to our burn center, and generated graphs showing the number of patient admissions by the daily average and maximum temperature (F).ResultsA total of 173 pavement related burn cases were identified in this 5-year period. 149 of these cases were isolated pavement burn injuries, and 24 cases involved pavement burns plus another mechanism of burn related injury. 79% of pavement burns admitted to our hospital occurred when the average atmospheric temperature was 90°F or greater, and 19% occurred when the average temperature was 100°F or greater. 92% of the cases occurred when the maximum recorded temperature for the day of injury was 100°F or greater.ConclusionsPavement burn related injuries can occur at a different range of atmospheric temperatures. There is a clear correlation between increase in atmospheric temperatures and pavement burns, with the majority of these burns occurring at average and maximum temperatures of 90°F or greater. This information can be used for burn prevention education, for any climate with daily maximum temperature over 100 F has the capability to suffer pavement burns.Applicability of Research to PracticeThe results of this study will help us determine the atmospheric temperature ranges at which the majority of patients are at risk for pavement related burn injuries. This will help us implement prevention and educational material to instruct our community on the dangers of hotter climate and pavement burn injuries.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.397
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 57 Association of Head and Neck Burns With Long-term Patient-reported
           Dissatisfaction With Appearance: A Burn Model System National Database
           Study
    • Authors: Sinha I; Nabi M, Simko L, et al.
      Abstract: IntroductionBurns affecting the head and neck (H&N) region may lead to significant changes in appearance. It is postulated that such injuries have a negative impact on patients’ social functioning, quality of life, physical health, and satisfaction with appearance, however, there has been little investigation of these effects using patient reported outcome measures. This study evaluates the long-term patient reported outcomes of patients with H&N burns compared to those with burns to other areas.MethodsData from the Burn Model System National Database collected between 1996 and 2015 were used to investigate differences in outcomes between those with and without H&N burns. Demographic and clinical characteristics for adult burn survivors were compared. The following PROMs were examined at 6, 12, and 24 months post-injury: Satisfaction With Life (SWL), Community Integration Questionnaire (CIQ), Satisfaction With Appearance (SWAP), Short Form-12 Physical Component Score (SF-12 PCS), and Short Form-12 Mental Component Score (SF-12 MCS). The associations between H&N burns and each outcome measure, controlling for medical and demographic characteristics were examined.ResultsA total of 697 adults (373 with H&N burns; 324 without H&N burns) were included in the analysis. The two groups were similar in age (H&N burns, 44.6±15.0 years; non-H&N burns, 44.8±15.9 years) and gender (H&N burns, 73.7% male; non-H&N burns, 71.6% male). The populations differed in etiology and burn size. Over 75% of H&N injuries resulted from a fire/flame burn and those with H&N burns had significantly larger burn size (p < 0.001). Using mixed model regression analyses, SWAP and SF-12 MCS were found to be significantly worse for adults with H&N burns compared to those with non-H&N burns (p < 0.01). There were no significant differences between the other PROMs.ConclusionsSurvivors with H&N burns demonstrated community integration, physical health, and satisfaction with life outcomes similar to those of survivors with non-H&N burns. Scores in these domains improved over time since burn injury. However, survivors with H&N burns continued to demonstrate worse satisfaction with their appearance.Applicability of Research to PracticeThe results suggest that survivors with head and neck burns need strategies to address satisfaction with appearance, such as reconstructive surgery, cognitive behavior therapy, and social skills training.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.060
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 418 Burn Outpatient, Patient Dressing/Medication Assistance
    • Authors: Klecka E; Alem P, Johansen S, et al.
      Abstract: IntroductionThe burn outpatient office sees over 1,000 new patients a year. Each patient requires a unique, individual treatment and wound care plan. The dressing supplies and topical required can be very costly if not covered by insurance, which is often the case. On average, each dressing change can cost $80.00-$90.00. As a result, patients return to the office more frequently for dressing changes, present to the ER, or fail to adhere to prescribed wound care recommendations. In January of 2017, a former patient identified this as a problem and donated funding to help patients obtain the dressing supplies they needed. A multidisciplinary team consisting of burn surgeons, nurses from the inpatient and outpatient areas, pharmacy staff and the burn foundation met to develop a solution for the ongoing financial dilemma affecting our patients.MethodsThe initial process identified all potential wound products that burn patients could possibly require for home care. During this process, the team developed, “The Center for Wound and Burn Healing Patient Dressing Assistance Request Program”, which ensures that patients will receive the physicians’ ordered supplies for the duration of one week. After the patient is identified to have financial need, the burn surgeons and outpatient burn staff work collaboratively to determine product needs and fill out an interdepartmental form. This form is taken to the pharmacy by the patient where their order is expedited and supplies are provided immediately. At the end of each month, the burn foundation reimburses the outpatient retail pharmacy for all products that are dispensed.ResultsAs of July 31st, 2018, 102 patients have directly benefited from the funds donated and the collaborative effort put forth by the various departments involved within the hospital. Collectively, $13,458 was saved, ensuring proper wound care and dressing supplies were available to the patients.ConclusionsDonated monies targeted for vulnerable populations within the burn community assisted to alleviate the financial stress for this group of patients and ensured they received dressing changes in a timely manner. This program also reduced outpatient visits and improved patient outcomes. Other burn centers should consider establishing a patient fund to assist with procuring dressing supplies for patients that are financially unable to.Applicability of Research to PracticeThe availability of no cost patient dressing supplies offers improved compliance with dressing treatment plans for financially vulnerable burn patients.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.315
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 460 Improving On-Time First Surgical Case Starts at a Pediatric Burn
           Facility
    • Authors: Hutson M; Boaze A.
      Abstract: IntroductionHospitals want to achieve optimal OR utilization to ensure effective management of resources and reduce waste. When the OR starts on time, there is a reduction in overtime and surgical cancellations resulting in improved employee and patient satisfaction. Multiple departments have an impact on OR start times as well. A multidisciplinary approach facilitates performance improvement in on-time first surgical case starts.MethodsFirst, we tracked the intake process of our day surgery patients, from their arrival to the facility to their admission in to the OR. We monitored the pre-operative flow of our PICU to determine areas for improvement. Communication was a common deficiency between both areas. The PICU did not have a strong pre-operative process for patients and the work fell on the OR nurse. We developed a pre-operative checklist for the PICU to implement and we improved communication of the surgical case order for PICU patients. Deficiencies for our day surgery assessment included timely patient arrival. We arranged for patients to arrive earlier, giving 1.5 hours for pre-operative preparation versus 30 minutes. Departments worked together daily to create and communicate a surgical case order and arrange for timely transportation of first cases. Most importantly, we gained staff buy-in, both at the department level and facility level. The faculty Chief of Staff met with the OR team to discuss the importance of on-time first case starts and its financial impact on the facility, as well as how it effects the number of children we care for. Department heads received the same information, as multiple disciplines affect start times in some form.ResultsIn quarter 1 of 2018 our on-time first case start rate was 36%, and 35% in quarter 2. After our interventions, our on-time first case start rate increased to 81% in quarter 3. Our Press-Ganey scores improved by 1.2 points. Through employee interviews, satisfaction has improved as staff can spend quality time with their patient in the pre-operative phase and feel less rushed. In starting surgeries on time, we have a reduction in after-hours cases and overtime. By being more efficient, we can increase the number of surgical cases performed daily. Overall, staff mostly enjoy providing care to as many patients as they can.ConclusionsImproving on-time first surgical case starts enhances operating room utilization and efficiency. It is important to take the time to observe the process and ensure accuracy of data. Identify and address deficiencies based on those observations. Most importantly, involve frontline staff, as employees are supportive when engaged in process improvement.Applicability of Research to PracticePerformance improvement process to support on-time first surgical case starts by applying a multidisciplinary team approach.
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.355
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 15 Trends in Pediatric Acuity at a Single Verified Burn Center
    • Authors: Dao S; Sociedade A, Rabbitts A.
      Abstract: IntroductionAn American Burn Association Verified Burn Center in a large metropolitan city has anecdotally experienced a decline in pediatric inpatient burn volumes and acuity. A literature review revealed three relative studies finding decreasing median burn size and incidence of pediatric burn admissions, and have found a correlation between increasing burn center pediatric volumes and decreased patient mortality. This research aims to objectively analyze this single institution’s trends in pediatric acuity over time in order to properly plan and adapt to the burn centers changing population.MethodsThe NTRACS burn registry was retrospectively reviewed for all patients admitted into the burn center from January 1, 2001 to December 31, 2017. Patients older than 18 and any readmission data were excluded. Patient age, gender, % of Admissions >15% TBSA, % of admissions >40% TBSA, inhalation injury diagnosis, ventilator requirement, and mortality rates were collected. Descriptive statistics were collected for age and gender. Simple linear regression was conducted to examine the trends of the remaining variables over time (year).Results4852 total patients met inclusion criteria. On average, males comprise of 55% of the population. The average age is 3.54 years old. Simple linear regression showed there was a significant inverse relationship between time (year) and incidence of admissions (p< 0.001), % of admissions >15% TBSA (p< 0.001), % of admissions >40% TBSA (p=0.002), ventilator requirement (p< 0.001), and mortality rate (p=0.003). There was no significant relationship with time and diagnosis of an inhalation injury (p= 0.356). (See Table 1).ConclusionsSimilar to the literature review, our research depicts declining pediatric admission incidence and acuity. However, contrary to the literature review, our mortality rate declined despite the declining burn volumes. Although this is a fortunate finding, this does not conclude our insusceptibility. As we are witnessing the decline of our pediatric burn admissions, our ability to adapt in order to maintain burn and age specific competencies become critical. Implementation of evolving care model systems, increased continuing education, and multidisciplinary staff support become necessity. Burn centers nationwide need to continually critically assess its ability to safely care for critically ill children and find care models that best serve our burn patients.Applicability of Research to Practice: Directly applicable
      PubDate: Fri, 08 Mar 2019 00:00:00 GMT
      DOI: 10.1093/jbcr/irz013.019
      Issue No: Vol. 40, No. Supplement_1 (2019)
       
  • 314 Inflammatory and Infectious Complications of Laser Therapy in
           Treatment of Hypertrophic Burn Scars: Correlations in Literature Review
           and Case Reports
    • Authors: Baletic N; Dabek R, Hughes C, et al.
      Abstract: IntroductionHypertrophic burn scars contribute to morbidity through secondary symptoms of pain, pruritus, and scar contracture. Traditional treatment methods are now augmented by the use of monochromatic light therapies, which are generally accepted as safe and effective. However, there is little literature available regarding the complications of laser treatments of hypertrophic burn scars and even less regarding inflammatory and infectious complications.MethodsA literature search using PubMed was performed to identify literature pertaining to infectious and inflammatory complications of cutaneous laser treatments. Additionally, we reviewed cases of inflammatory and infectious complications occurring at our institute after laser treatment of hypertrophic burn scars.ResultsWe only identified 1 publication related to complications of laser therapy in the treatment of burn scars. In 163 laser sessions, the reported incidence of adverse events was 25.1%, of which only 14.6% were related to infectious processes. Nine cases of inflammatory and infectious complications were observed at our institute between Dec, 2015 and Jul, 2016. Cases included 3 each of cellulitis, Systemic Inflammatory Response Syndrome (SIRS), and complicated SIRS.ConclusionsWe found the most common inflammatory complication was SIRS with MSSA positive wound cultures. Three cases required hospitalization, antibiotics, fl