Surviving Sepsis After Burn Campaign

INTRODUCTION

The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes.

METHODS

The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported.

RESULTS

The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis.

CONCLUSION

Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.

Infections in Burn Patients

Infections are the leading cause of mortality in burn patients who survive their initial resuscitation. Burn injury leads to immunosuppression and a dysregulated inflammatory response which can have a prolonged impact. Early surgical excision along with support of the multidisciplinary burn team has improved mortality in burn patients. The authors review diagnostic and therapeutic challenges as well as strategies for management of burn related infections.

Modified Frailty Index is an Independent Predictor of Death in the Burn Population: A Secondary Analysis of the Transfusion Requirement in Burn Care Evaluation (TRIBE) Study

Frailty can increase the risk of dying after suffering a severe injury. The Modified Frailty Index (MFI) was developed by the American College of Surgeons National Surgical Quality Improvement Program to determine the impact of frailty on outcomes. Our aim was to correlate frailty with survival following a burn injury using the 11-item and 5-item MFI. We performed a secondary analysis of the Transfusion Requirement in Burn Care Evaluation (TRIBE) study. Data including, age, gender, medical history, extent and severity of burn injury, inhalation injury and discharge disposition was collected from the TRIBE database. The 11-item MFI (MFI-11) and 5-item MFI (MFI-5) scores were calculated for all patients in the TRIBE database. The TRIBE database included 347 patients. The mean age of subjects was 43 ± 17 years. Mean total body surface area burn (TBSA) was 38 ± 18%, and 23% had inhalation injury. Multivariate logistic regression analysis determined that both MFI-5 (OR 1.86; 95% CI: 1.11-3.11; P-value .02) and MFI-11 (OR 1.83; 95% CI: 1.18-2.8; P-value .007) were independent predictors for mortality. Additionally, MFI-11 scores that are >1 were independently associated with a markedly increased risk of dying after a burn injury (OR 2.91; 95% CI: 1.1-7.7; P-value .03). The MFI can be used to identify vulnerable burn injured patients who are at high risk of dying.

Burn Resuscitation Practices in North America: Results of the Acute Burn ResUscitation Multicenter Prospective Trial (ABRUPT)

OBJECTIVES

ABRUPT was a prospective, noninterventional, observational study of resuscitation practices at 21 burn centers. The primary goal was to examine burn resuscitation with albumin or crystalloids alone, to design a future prospective randomized trial.

SUMMARY BACKGROUND DATA

No modern prospective study has determined whether to use colloids or crystalloids for acute burn resuscitation.

METHODS

Patients ≥18 years with burns ≥ 20% total body surface area (TBSA) had hourly documentation of resuscitation parameters for 48 hours. Patients received either crystalloids alone or had albumin supplemented to crystalloid based on center protocols.

RESULTS

Of 379 enrollees, two-thirds (253) were resuscitated with albumin and one-third (126) were resuscitated with crystalloid alone. Albumin patients received more total fluid than Crystalloid patients (5.2 ± 2.3 vs 3.7 ± 1.7 mL/kg/% TBSA burn/24 hours), but patients in the Albumin Group were older, had larger burns, higher admission Sequential Organ Failure Assessment (SOFA) scores, and more inhalation injury. Albumin lowered the in-to-out (I/O) ratio and was started ≤12 hours in patients with the highest initial fluid requirements, given >12 hours with intermediate requirements, and avoided in patients who responded to crystalloid alone.

CONCLUSIONS

Albumin use is associated with older age, larger and deeper burns, and more severe organ dysfunction at presentation. Albumin supplementation is started when initial crystalloid rates are above expected targets and improves the I/O ratio. The fluid received in the first 24 hours was at or above the Parkland Formula estimate.

Proceedings of the 2021 American Burn Association State and Future of Burn Science Meeting

Periodically, the American Burn Association (ABA) has convened a State of the Science meeting on various topics representing multiple disciplines within burn care and research. In 2021 at the request of the ABA President, meeting development was guided by the ABA's Burn Science Advisory Panel (BSAP) and a subgroup of meeting chairs. The goal of the meeting was to produce both an evaluation of the current literature and ongoing studies, and to produce a research agenda and/or define subject matter-relevant next steps to advance the field(s). Members of the BSAP defined the topics to be addressed and subsequently solicited for nominations of expert speakers and topic leaders from the ABA's Research Committee. Current background literature for each topic was compiled by the meeting chairs and the library then enhanced by the invited topic and breakout discussion leaders. The meeting was held in New Orleans, LA on November 2nd and 3rd and was formatted to allow for 12 different topics, each with two subtopics, to be addressed. Topic leaders provided a brief overview of each topic to approximately 100 attendees, followed by expert-lead breakout sessions for each topic that allowed for focused discussion among subject matter experts and interested participants. The breakout and topic group leaders worked with the participants to determine research needs and associated next steps including white papers, reviews and in some cases collaborative grant proposals. Here, summaries from each topic area will be presented to highlight the main foci of discussion and associated conclusions.

BACTERIAL PATHOGEN-ASSOCIATED MOLECULAR PATTERNS UPREGULATE HUMAN GLUCOCORTICOID RECEPTOR EXPRESSION IN PERIPHERAL BLOOD MONONUCLEAR CELLS

ABSTRACT

It is well known that bacterial components (pathogen-associated molecular patterns [PAMPs]) induce a proinflammatory response through pattern recognition receptor signaling. What is not known, however, is how the inflammatory response is downregulated. We hypothesize that bacterial products initiate compensatory anti-inflammatory responses by inducing expression of the human glucocorticoid receptor (hGR). Peripheral blood mononuclear cells (PBMCs) were isolated from leukocytes concentrated from single human donors (Leukopaks). PBMCs were treated with a gram-negative bacterial component, LPS, or gram-positive bacterial components, lipoteichoic acid (LTA) or peptidoglycan (PGN), for 1, 3, or 13 h. Protein expression of hGR was evaluated by Western blot analysis. RNA was extracted from similarly treated cells for reverse transcription-polymerase chain reaction analysis of hGR and cytokine expression. At 13 h after LPS treatment, there was an increase in the reference hGR protein (hGRα) expressed within some but not all PBMCs isolated from Leukopaks. There was also a dose-dependent increase in hGRα expression with increasing concentrations of PGN (10 and 50 μg/mL). LTA, however, did not affect hGRα expression. PGN also increased the mRNA expression of an hGR splice variant, hGR-B(54). The mRNA expression changes for the inflammatory cytokines were Leukopak specific. We found that cell wall components of both gram-positive and gram-negative bacteria can increase the expression of hGRα. Although these PAMPs augment the inflammatory response, it seems that there is a simultaneous upregulation of hGRα expression. Because binding of cortisol to hGRα typically induces anti-inflammatory proteins, the same PAMPs that induce an inflammatory response seem to also initiate a negative feedback system by inducing hGRα expression in PBMCs.

Suicide by self-inflicted burns - A persistent psychiatric problem

Self-inflicted burns are a relatively uncommon but profound attempt at suicide. Twenty years ago, we first reviewed our experience with self-inflicted burns. With this current study, we sought to determine whether there had been any change in the incidence or outcomes of self-inflicted burns. All burn patients admitted between January 1, 2012, and December 31, 2021, with self-inflicted burns were compared with all other admissions. The frequency of self-inflicted burns and confounding risk factors of patients with self-inflicted burns remained unchanged. A large proportion (87.4 %) of the patients had psychiatric disease. They also had larger burns and higher mortality than accidental burns. Unexpectedly, logistic regression analysis that controlled for age, total percent total body surface area (TBSA) burn, sex, and inhalation injury revealed that those patients with self-inflicted burns had 72 % lower odds of dying than the general population. In conclusion, there has been no improvement in the incidence of self-inflicted burns. They result in very severe injuries, but when age, burn size, gender, and inhalation injury are controlled for, they have at least as good a chance for survival as the general burn population.

521 Maintaining Central Line Patency in Burned Children

Introduction

Children with major burn injury frequently require prolonged central venous access to assure appropriate fluid management and pain control. Central venous catheters in children frequently develop clots that prevent drug administration, requiring administration of tissue plasminogen activator (TPA). The purpose of this study was to identify the frequency and efficacy of TPA use in burned children with central venous catheters (CVC).

Methods

This retrospective chart review evaluated all children requiring CVC admitted to our tertiary pediatric burn center from 2018-2019. Data collected included patient demographics (age, burn size, hospital length of stay (LOS)), catheter-related data (number of central lines, lines replaced due to clotting), TPA administration (number of times administered, successful TPA administrations, how often repeated), and line clotting data (time from insertion to clot, interval between TPA order and administration).

Results

In 2018, 116 lines were place in 49 children with mean age of 8.4 years and mean burn size of 29%, intensive care unit LOS was 24 days. TPA was infused in 20% of lines to relieve obstruction and was successful in relieving the clot in 21% (5/23). The interval between identification of the obstructed line to TPA order was 191 minutes, with the administration of TPA 83 minutes after order placement. The average time from identification of obstruction to TPA administration was 257 minutes. In 2019, 150 lines were place in 65 children with mean age of 5.2 years and mean burn size of 25%, LOS was 13 days in the PICU. TPA was infused in 5% of lines to relieve obstruction and was successful in relieving the clot in 0 % (0/8). The interval between identification of the obstructed line to TPA order was 117 minutes, with the administration of TPA 49 minutes after order placement. The average time from identification of obstruction to TPA administration was 158 minutes.

Conclusions

The incidence of obstruction in pediatric central venous catheters in our unit decreased from 26% in 2018 to 3% in 2019. TPA was successful in clot resolution in only 5% (2018), and 0% (2019) . Based on our results, we targeted areas for improvement including: Standing order for TPA; staff education on TPA use; decreasing our average time to identify, order, and administer TPA; and standardizing the frequency of flushing unused central venous catheter lumens with heparinized saline flush.

794 Use of Cultured Epithelial Autografts After Biodegradable Temporizing Matrix in Massive Burns

Introduction

As burn care advances, patients are surviving with larger burn injuries, that previously would have been fatal. However, the need for autologous skin coverage continues to be an unmet need for massive burn injuries. Several attempts have been made to address this with various dermal substitutes, temporary coverage, and skin substitutes. For 25 years, Cultured Epithelial Autografts (CEA) have been used to treat large burn injuries, but this was met with variable success and has a mandatory pre-requisite lab time before it is ready for use. In 2018, Biodegradable Temporizing Matrix (BTM) that can be placed immediately on excised burns was first studied in burn patients, which has led to its increased use in subsequent years. This case series seeks to examine our experience using CEA following the application and ingrafting of BTM on large burns.

Methods

A retrospective review was conducted from 2017-2020 of adult burn patients admitted to an ABA verified burn center who underwent placement of both BTM and CEA. Demographics, mechanism of injury, burn characteristics, surgeries, and outcome data were collected. Surgical technique was early excision, BTM placement, a BTM integration period, repeat superficial excision, fibrin/thrombin spray, split thickness skin grafting with usually 6:1 mesh autograft, and finally CEA application. CEA was managed per manufacturer protocols. Descriptive statistics and univariate analyses were performed with Microsoft Excel.

Results

Eight patients met inclusion criteria. The average age was 29.3±5.3 years, 2nd degree TBSA 22.5±22.6%, 3rd degree TBSA 55.8±21%, and total TBSA was 78.3±4.4%. Four patients died during their hospital course and four survived to discharge. For survivors, the age length of stay was 135±23.6 days and they underwent an average of 8.5±1.5 total excision and/or grafting procedures. All patients had severe complications including severe sepsis/septic shock (n=8), gastrointestinal bleeds (n=2), acute respiratory distress syndrome (n=3), acute kidney injury or renal failure (n=4), pulmonary embolism (n=1) and myocardial infarction (n=1). The average time to 95% wound closure was 5 (79-147) days for survivors.

Conclusions

There continues to be an unmet need for autologous skin coverage in massive burn injuries when there is insufficient donor skin. In this series, we describe eight patients with massive burn injuries who underwent initial BTM placement, followed by 6:1 meshed autograft and CEA application. Although four patients died during their treatment course, the four surviving patients had acceptable wound closure rates and length of stay for their burn size.

777 Improving Parent Communication With Family Rounds In The Pediatric Critical Care Unit (PICU)

Introduction

Effective communication between pediatric burn patients, their family members and the health care team is crucial to developing a "working alliance" and improving their overall experience in the Pediatric Intensive Care Unit (PICU). The aim of the project is to standardize and improve patient and parent communication through the implementation of weekly inter-disciplinary family rounds.

Methods

Our nursing team developed the innovate PICU survey which is a 9 question Likert scale survey that evaluates patient and family satisfaction. All pediatric patients being discharged or transferred from the PICU received the PICU survey. After reviewing baseline data, communication between patient/parents and the health care team was identified as a potential targeted area for improving satisfaction scores. Aimed at improving communication, we established weekly inter-disciplinary family rounds. Each family was designated a specific day of the week for inter-disciplinary family rounds and staff provided families with a pre-printed standardized flyer explaining the process and were encouraged to write down questions for discussion. Survey scores from burn patients who received inter-disciplinary family rounds were compared to baseline scores, as well as to the scores of other pediatric patients of services that do not utilize family rounds.

Results

Prior to implementing family rounds, our PICU survey average score was 4.9/5 out of 6 surveys. After implementing inter-disciplinary family rounds, our average score for pediatric burn patients was 4.9/5 out of 10 surveys. The average scores of pediatric patients of services that did not utilize family rounds 4.7/5 out of 19 surveys.

Conclusions

Scheduled inter-disciplinary family rounds can improve communication and over patient care satisfaction in pediatric patients with complex critical care issues related to burn injuries. Scheduled family rounds may also be beneficial for other non-burn pediatric ICU patients.

733 Massive Burn Injuries: Characteristics, Treatment Strategies and Outcomes from a Single Institution

Introduction

Advances in burn care have led to improved survival, with survival after a 50% total body surface area (TBSA) or larger burn being more common. Traditionally, age, TBSA burned, inhalation injury, delayed resuscitation and evidence of early organ dysfunction have been predictive of survival. The goal of this study was to describe a large series of massive burn injuries, treatment strategies and identify factors related to survival.

Methods

Following IRB approval, a retrospective review of adult patients who sustained 50% TBSA or larger burn from 8/2009 to 7/2019 at an ABA verified burn center was conducted. Demographic, burn size/depth, mechanisms of injury, treatments, and outcome data were collected. Univariate and multivariate analyses were performed using R statistical software (R-project.org).

Results

155 patients were included which was 4.7% (155/3312) of all burn admissions during that time internal. Patients had an average age of 44±18 years, a male predominance (79%), and average TBSA burned of 70±15%. Overall mortality was 54% (83/155). One third of patients were transitioned to comfort care. The 103 treated patients were younger (37±12 vs 59±19 years; p=< 0.0001), more likely to be male (85 vs 65%; p=0.006), had smaller average TBSA (66±13 vs 78±16%; p< 0.0001) and more likely to have a psychiatric condition (31 vs 13%; p=0.02). Approximately 70% of treated patients survived to discharge. Survivors were more likely to have smaller TBSA (63±13 vs 73±13; p=0.001) and less third-degree burns (49±24 vs 61±24; p=0.01). One third of treated patients developed renal failure. One quarter of patients had a mental health condition, and these patients spent more time in the hospital (61 vs 31 days; p=0.009), more time on ventilator (29 vs 12 days; p=0.046), required more surgery (3 vs 2; p=0.048), and were less likely to die (36% vs 59%; p=0.02). On multivariate regression analysis of treated patients, psychiatric illness (OR 0.19; p=0.03) and burns related marijuana/hash oil production (OR 0.13; p=0.015) were protective against mortality.

Conclusions

Surviving burns >50% TBSA is becoming more common as burn care continues to improve. Mortality in this study is lower than what would be predicted by an established revised Baux score regression model (predicted 61% overall mortality and 48% for treated). Care for these massive burn injuries is complex and requires an experienced multidisciplinary team. There is an established link between burn injuries and mental health conditions. Despite similar burn size/depth, patients with a mental health history spent significantly more time in the hospital, more time on the ventilator and required more surgery.

Does Socioeconomic Status or Methamphetamine use Impact Discharge Opioid Requirements in Burn Injured Patients?

Methamphetamine (MA) use is associated with lower socioeconomic status (SES) and increased opioid use. Though MA use itself has been linked to larger burn injuries and increased length of stay, studies examining the effect of SES on opioid use in this patient population remain limited. The aim of this work was to examine how both SES and/or MA use in burn patients impacted discharge opioid requirements. Records of burn patients admitted to an ABA verified burn center were reviewed from January 2016 to December 2017. Patients were grouped into MA positive (MPOS) or negative groups (MNEG) based on admission urine toxicology screening. Pain scores, oral morphine opioid equivalents (OE), and adjunct pain medication use reported within 24 hours of discharge were examined. SES was determined by zip code. No difference was found between MPOS and MNEG groups regarding discharge OE (p=0.4), OE/TBSA (p=0.79), or pain score (p=0.09). Low SES was more prevalent in MPOS patients (p&lt;0.0001) but low SES was not a predictor of discharge OE (p=0.7), OE/TBSA (p=0.7), or pain score (p = 0.15). Discharge OE and OE/TBSA requirements correlated with discharge pain score (p&lt;0.0001) and LOS (p&lt;0.01), but not SES. Multivariate linear regression found that MNEG status (p=0.005), pain score (p &lt; 0.0001), concurrent use of benzodiazepines and gabapentin (p&lt;0.001), but not low SES, were independently associated with increased OE. Although lower SES was seen in patients using MA, SES was not associated with discharge opioid use or pain scores. Additional work will be necessary to determine factors affecting opioid use in this population.

Face Burns: A 4-Year Experience

Burns on the face pose unique management challenges because they are in a place that is constantly visible, so scars are hard to hide. The goal of this study was to review our experience of adult patients who had face burns. We performed a retrospective review of adult patients (≥18 years old) who were admitted to a regional burn center from July 2015 to June 2019 with face burns. Sex, age, ethnicity, burn etiology, burn size, and discharge status were collected from electronic medical records of the patients who met study criteria. Descriptive statistics, Student's t-tests, and chi-square tests were performed in Stata/SE 16.1. Significance was defined as a P-value < .05. In 4 years, 595/1705 patients (~35% of admissions) were admitted with face burns. The mean age was 44.9 ± 17.0 (mean ± SD) years, with the majority being men (475, 80%). The mean burn size was 19.8 ± 20.9% TBSA with 10.1 ± 19.8% TBSA being third degree. The mean head burn size for any face burn was 2.8 ± 1.8% TBSA. The majority of burns were due to flames (478, 80%) and of those 122 (21%) were from accelerant use and 43 (7%) resulted from propane or butane use. Scalds caused 53 (9%), electric 25 (4%), hot tar 5 (1%), and chemical 5 (1%). Overall, 208 (35%) patients had grafting of some portion of their body, but only 31 patients (5.2%) had face grafting. The mean age of those with face grafting compared with patients who did not need grafting was 45.9 ± 13.8 and 44.9 ± 17.2 years, respectively. Patients who needed grafting had a mean third-degree burn size of 31.7 ± 25.4% TBSA and a mean head (including face) burn size of 4.7 ± 2.0% TBSA, whereas patients who did not need grafting had a mean third-degree burn size of 8.9 ± 18.7% TBSA and a mean head burn size of 2.7 ± 1.8% head TBSA. Patients requiring face grafts had longer lengths of stay, intensive unit stays, ventilator days, and mortality than those whose face burns healed spontaneously. Overall, head burns in adults were common within the 4-year time span we studied, but only a small fraction (5%) had face grafts. The patients who needed grafting for their head burns had significantly larger total body and face burns and had a 2.4-fold higher mortality rate compared to patients who did not need grafting. Most face burns were caused by flame, especially the use of accelerants or flammable gases. Prevention efforts should focus on avoiding the use of accelerants and being careful with flammable gases.

Understanding factors in burn patient follow-up

Follow-up rates (FUR) are concerningly low among burn-injured patients. This study investigates the factors associated with low FUR and missed appointments (MA). We hypothesize that patients who are homeless, use illicit substances, and have psychiatric comorbidities will have lower rates of follow-up (FU) and more MAs. Data from a discharge-planning survey of 281 burn-injured patients discharged from September 2019 - July 2020 was analyzed and matched with patients' EMR records for a retrospective chart review. Data collected included general demographics, burn characteristics, hospitalization details, FU visits, MAs, homeless status, substance use, major psychiatric illness (MPI), and survey responses. Data analysis used Chi-square, Fisher's exact test, Student t-test, Wilcox Rank Sum test, and Multivariate Regression Analysis (MVR). Overall, 37% of patients had no FU in clinic and 46% had one or more MA. On MVR, homeless patients were more likely to never follow up, OR = 0.227 (95% CI = 0.106-0.489), as were patients who anticipated transportation difficulties, OR = 0.275 (95% CI = 0.151-0.501). Homeless patients were more likely to have MA, OR= 0.231 (95% CI = 0.099-0.539). On univariate analysis, patients with one or more documented MPI had lower FUR, with 50.62% having no FU (p = 0.0020). Among patients who responded to the survey that they were current drug users, 52% had no FU as compared to 28% of patients who responded that they did not use drugs (p = 0.0007). Factors associated with lower FUR and more MAs include homeless status, substance use, MPI, and transportation difficulties.

Examining 1:1 vs. 4:1 Packed Red Blood Cell to Fresh Frozen Plasma Ratio Transfusion During Pediatric Burn Excision

Blood transfusions following major burn injury are common due to operative losses, blood sampling, and burn physiology. While massive transfusion improves outcomes in adult trauma patients, literature examining its effect in critically ill children is limited. The study purpose was to prospectively compare outcomes of major pediatric burns receiving a 1:1 vs. 4:1 packed red blood cell to fresh frozen plasma transfusion strategy during massive burn excision. Children with >20% total body surface area burns were randomized to a 1:1 or 4:1 packed red blood cell/fresh frozen plasma transfusion ratio during burn excision. Parameters examined include patient demographics, burn size, pediatric risk of mortality (PRISM) scores, pediatric logistic organ dysfunction scores, laboratory values, total blood products transfused, and the presence of blood stream infections or pneumonia. A total of 68 children who met inclusion criteria were randomized into two groups (n = 34). Mean age, PRISM scores, estimated blood loss (600 ml (400-1175 ml) vs. 600 ml (300-1150 ml), P = 0.68), ventilator days (5 vs. 9, P = 0.47), and length of stay (57 vs. 60 days, P = 0.24) had no difference. No differences in frequency of blood stream infection (20 vs. 18, P = 0.46) or pneumonia events (68 vs. 116, P = 0.08) were noted. On multivariate analysis, only total body surface area burn size, inhalation injury, and PRISM scores (P < 0.05) were significantly associated with infections.

Wildfire Burn Patients: A Unique Population

In the past ten years wildfires have burned an average of 6.8 million acres per year and this is expected to increase with climate change. Wildfire burn patient outcomes have not been previously well characterized. Wildfire burn patients from the Tubbs or Camp wildfires and non-wildfire burn matched controls were identified from the burn center database and outcomes were compared. The primary outcome was mortality. Secondary outcomes included length of stay (LOS), intensive care unit (ICU) LOS, readmission and development of wound infections. Time of presentation and operating room use after wildfires was evaluated. Sixteen wildfire burn patients were identified and matched with 32 controls. Wildfire burn patients trended towards higher mortality (19% wildfire vs. 9% non-wildfire, p=0.386), longer LOS (18 days wildfire vs. 15 days non-wildfire, p=0.406), longer ICU LOS (17 days wildfire vs. 11 days non-wildfire, p=0.991), increased readmission (19% wildfire vs. 3% non-wildfire, p=0.080) and higher rates of wound infection (31% wildfire vs. 19% non-wildfire, p=0.468). The majority of wildfire patients (88%) presented within 24 hours of the wildfire reaching a residential area. Operating room time within the first week was 13 hours 44 minutes for the Tubbs Fire and 19 hours 1 minute for the Camp Fire. Patients who sustain burns in wildfires are potentially at increased risk of mortality, prolonged LOS, wound infection and readmission.

Longitudinal profiling of the burn patient cutaneous and gastrointestinal microbiota: a pilot study

Sepsis is a leading cause of morbidity and mortality in patients that have sustained a severe burn injury. Early detection and treatment of infections improves outcomes and understanding changes in the host microbiome following injury and during treatment may aid in burn care. The loss of functional barriers, systemic inflammation, and commensal community perturbations all contribute to a burn patient’s increased risk of infection. We sampled 10 burn patients to evaluate cutaneous microbial populations on the burn wound and corresponding spared skin on days 0, 3, 7, 14, 21, and 28 post-intensive care unit admission. In addition, skin samples were paired with perianal and rectal locations to evaluate changes in the burn patient gut microbiome following injury and treatment. We found significant (P = 0.011) reduction in alpha diversity on the burn wound compared to spared skin throughout the sampling period as well as reduction in common skin commensal bacteria such as Propionibacterium acnes and Staphylococcus epidermitis. Compared to healthy volunteers (n = 18), the burn patient spared skin also exhibited a significant reduction in alpha diversity (P = 0.001). Treatments such as systemic or topical antibiotic administration, skin grafting, and nutritional formulations also impact diversity and community composition at the sampling locations. When evaluating each subject individually, an increase in relative abundance of taxa isolated clinically by bacterial culture could be seen in 5/9 infections detected among the burn patient cohort.

Follow-up After Burn Injury Is Disturbingly Low and Linked With Social Factors

For medical and social reasons, it is important that burn patients attend follow-up appointments (FUAs). Our goal was to examine the factors leading to missed FUAs in burn patients. A retrospective chart review was conducted of adult patients admitted to the burn center from 2016 to 2018. Data collected included burn characteristics, social history, and zip code. Data analysis was conducted using chi-square, Wilcoxon Rank-Sum tests, and multivariate regression models. A total of 878 patients were analyzed, with 224 (25.5%) failing to attend any FUAs and 492 (56.0%) missing at least one appointment (MA). Patients who did not attend any FUAs had smaller burns (4.5 [8]% vs 6.5 [11]% median [inter quartile range]), traveled farther (70.2 [111.8] vs 52.5 [76.7] miles), and were more likely to be homeless (22.8% vs 6.9%) and have drug dependence (47.3% vs 27.2%). Patients who had at least one MA were younger (42 [26] vs 46 [28] years) and more likely to be homeless (17.5% vs 2.6%) and have drug dependence (42.5% vs 19.4%). On multivariate analysis, factors associated with never attending an FUA were distance from hospital (odds ratio [OR] 1.004), burn size (OR 0.96), and homelessness (OR 0.33). Factors associated with missing at least one FUA: age (OR 0.99), drug dependence (OR 0.46), homelessness (OR 0.22), and Emergency Department visits (OR 0.56). A high percentage of patients fail to make any appointment following their injury and/or have at least one MA. Both FUAs and MAs are influenced by social determinants of health.

101 Homeless Status, Distance from Clinic, and Substance Dependence Associated with Low Follow-Up Rates for Burn-Injured Survey Respondents

Introduction

Over 25% of burn-injured patients at our institution never attended a follow-up appointment. A quality-improvement discharge survey (QIS) identified potential barriers to follow-up as distance from the clinic, transportation, and time off work. This study compares follow-up rates before and after the QIS was administered and correlates them with patients’ self-identified barriers.

Methods

Following IRB approval, a retrospective chart review was conducted using electronic medical records of adult burn-center admits who responded to the QIS and were discharged between September 2019 and July 2020. Controls were burn-center admits discharged from 2016–2018, prior to the survey period. Exclusions included patients with non-burn injuries, and those who died in the hospital were transferred to another hospital, did not require follow-up, or followed up elsewhere. Data analysis was conducted using chi-square, t-test, and logistic regression models.

Results

The post-survey group includes 272 patients (mean age 47 ± 16.8, 201 males (73.6%), mean burn size (TBSA) of 9.3% ± 9.6%). The pre-survey control group includes 878 patients (mean age 45.1 ± 16.8 years, 646 males (73.6%), mean burn size (TBSA) 10.16 ± 11.7%). Compared to the pre-survey group, post-survey patients had a lower frequency of missed appointments (MA) (47.3% post vs. 56% pre), but worse overall follow-up rates (63.7% post vs. 74.5% pre). Per multivariate analysis, different factors were associated with follow-up and MA in the two groups (Table 1). Rates of follow-up and MA were not significantly different before and after the onset of the Covid-19 pandemic.

Conclusions

Patients who were surveyed to identify barriers to follow-up had fewer missed appointments but worse overall follow-up rates. Patients fail to follow up due to homelessness, substance dependence, and distance to the hospital. These findings are consistent with patients’ self-identified barriers to follow-up in a QI survey.

42 COVID-19 Slowdown? Not in Our Burn Center!

Introduction

There has been a great concern that the COVID-19 pandemic has interfered with burn care. The feeling has been that resources have been shifted to treating the COVID patients and that “shelter-in-place” requirements have reduced the risks for burn injury. The ABA and other organizations have sent biweekly surveys in order to determine how the pandemic has interfered with burn care. Despite these concerns, we seemed very busy.

Methods

The inpatient data was collected in our adult and pediatric burn centers between January 1, 2020 and August 31, 2020.

Results

During the COVID-19 pandemic there was an increase in burn admissions in both adult and pediatric centers. At the same time there were 1270 COVID-19 adult admissions and 4 COVID-positive admissions at the pediatric center. In the adult center, there was increase from 414 total admissions from fiscal year 2019 (7/2018-6/2019) of 414 to 495 for fiscal year 2020 (7/2019-6/2020). The average daily census also increased from 18.33 to 18.36 during the same period. The monthly number of burn admissions increased from 38.5/month for the last six months of 2019 to 44/month for the first six months of 2020. The admission rate continued in July (41) and August (47). In the first 8 months of 2020, there were 356 admissions with a mean TBSA of 11.3%. There were many large burns admitted in late summer. The mean TBSA of the 12 bed ICU on September 11, 2020 was 60.6% (range 25–85%). In the pediatric unit, there were 174 admissions through July 2020, a 6% increase from the preceding same period. There was a 6% decrease in burn reconstruction.

Conclusions

Despite a significant burden of COVID-19 patients, burn admissions also increased at the same time. There was no evidence that “shelter-in-place” requirements changed the risk for burn injuries. Resources for critical care needs should not be siphoned away from burn centers during pandemics. Risky behaviors leading to burns do not go away despite new health crises.

Clinical and Socioeconomic Differences in Methamphetamine-Positive Burn Patients

Previous research on burn patients who test positive for methamphetamines (meth) has yielded mixed results regarding whether meth-positive status leads to worse outcomes and longer hospitalizations. We hypothesized that meth-positive patients at our regional burn center would have worse outcomes. We reviewed burn admissions from January 2014 to December 2017 and compared total patients versus meth-positive, and matched meth-negative versus meth-positive for total BSA burn, length of stay (LOS), intensive care unit (ICU) days, days on ventilator, discharge status (lived/died), number of operating room (OR) visits, number of procedures, socioeconomic status, comorbidities, and discharge disposition. Of 1363 total patients, 264 (19.4%) were meth-positive on toxicology screen. We matched 193 meth-positive patients with meth-negative controls based on TBSA burn, age, and inhalation injury. In the total population comparison, meth-positive patients had larger burns (15.6% vs 12.2%; P = .004), longer LOS (17.8 vs 14.3 days; P = .041), and fewer operations/TBSA (0.12 vs 0.2; P = .04), and lower socioeconomic status. Meth-positive patients were less likely to be discharged to a skilled nursing facility, and more likely to leave against medical advice. In the matched patients, we found no significant differences in LOS or OR visits/TBSA burn. Meth-positive patients have lower socioeconomic status, larger burns, and longer LOS compared to the total burn population. Methamphetamine use, by itself, does not appear to change outcomes. Methamphetamine use leads to larger burns in a population with fewer resources than the general population.

Management of facial burns

Burns to the face affect a part of the body that cannot be hidden and thus exposes potentially major changes in appearance to society. Therefore, it is incumbent upon the caregiver to optimize healing and minimize scarring. The goal for partial-thickness burns is to have them heal within 2-3 weeks to minimize healing time. For full-thickness burns there needs to be strategies to optimize the outcomes for skin grafting and minimize scarring. The goal of this review is to discuss the best way to improve the outcomes of these devastating injuries.

A Comparative Study of the ReCell® Device and Autologous Spit-Thickness Meshed Skin Graft in the Treatment of Acute Burn Injuries

Early excision and autografting are standard care for deeper burns. However, donor sites are a source of significant morbidity. To address this, the ReCell^® Autologous Cell Harvesting Device (ReCell) was designed for use at the point-of-care to prepare a noncultured, autologous skin cell suspension (ASCS) capable of epidermal regeneration using minimal donor skin. A prospective study was conducted to evaluate the clinical performance of ReCell vs meshed split-thickness skin grafts (STSG, Control) for the treatment of deep partial-thickness burns. Effectiveness measures were assessed to 1 year for both ASCS and Control treatment sites and donor sites, including the incidence of healing, scarring, and pain. At 4 weeks, 98% of the ASCS-treated sites were healed compared with 100% of the Controls. Pain and assessments of scarring at the treatment sites were reported to be similar between groups. Significant differences were observed between ReCell and Control donor sites. The mean ReCell donor area was approximately 40 times smaller than that of the Control (P < .0001), and after 1 week, significantly more ReCell donor sites were healed than Controls (P = .04). Over the first 16 weeks, patients reported significantly less pain at the ReCell donor sites compared with Controls (P ≤ .05 at each time point). Long-term patients reported higher satisfaction with ReCell donor site outcomes compared with the Controls. This study provides evidence that the treatment of deep partial-thickness burns with ASCS results in comparable healing, with significantly reduced donor site size and pain and improved appearance relative to STSG.

Cervical Spine Injury in Burned Trauma Patients: Incidence, Predictors, and Outcomes

Cervical spine injuries (CIs) carry significant morbidity and mortality; hence, cervical spine immobilization is used liberally in trauma patients, including burns. The incidence, predictors, and outcomes of CI in burn patients are unknown. A retrospective cohort from the National Trauma Data Bank between 2007 and 2012 included all burned patients with and without CI. Predictors of CI were identified by logistic regression. Outcomes with and without CI were compared with Wilcoxon rank sum test. A total of 94,964 patients were identified with burn injuries. The incidence of CI was 0.79% (n = 745). Mechanism of injury, age, and injury severity score (ISS) were significant predictors of CI. Odds of CI were 109.4 (95% CI: 61.2-195.3, P < .0001) for motor vehicle injury, 87.8 (95% CI: 47.0-164.0, P < .0001) for falls, 1.2 (95% CI: 0.6-2.3, P = .66) for fire/flame, and 2.4 (95% CI: 1.0-5.5, P < .0001) for explosion compared with reference of hot object/substance. For every year increase in age, there were 1.02 higher odds of CI (95% CI: 1.01-1.02, P < .0001). For each point increase in ISS, there were 1.05 higher odds of CI (95% CI: 1.04-1.05, P < .0001). Patients with CI had higher mortality (10.3% vs 2.9%, P < .0001), longer total length of stay (12.0 vs 2.0 days, P < .0001), intensive care unit length of stay (4.0 vs 0.0 days, P < .001), and ventilator days (1.0 vs 0.0 days, P < .0001). The incidence of CI in burn patients is low, especially when due to fire, flame, or scalds; however, CI is associated with higher mortality and worse outcomes.

Uncovering a multitude of human glucocorticoid receptor variants: an expansive survey of a single gene

Background

Glucocorticoids are commonly used in the clinical setting for their potent anti-inflammatory effects; however, significant variations in response to treatment have been demonstrated. Although the underlying mechanisms have yet to be fully understood, this variable response may be a result of alterations in human glucocorticoid receptor (hGR) expression and function. In addition to hGRα, the biologically active isoform, a screening of current databases and publications revealed five alternative splice isoforms and hundreds of variants that have been reported to date. Many of these changes in the hGR-coding gene, NR3C1, have been linked to pathophysiology. However, many studies focus on evaluating hGR expression in vitro or detecting previously reported variants.

Results

In this study, blood from healthy volunteers, burn and asthma patients, as well as from peripheral blood mononuclear cells isolated from leukoreduced donor whole blood, were screened for NR3C1 isoforms. We identified more than 1500 variants, including an additional 21 unique splice isoforms which contain 15 new cryptic exons. A dynamic database, named the Universal hGR (UhGR), was created to annotate and visualize the variants.

Conclusion

This identification of naturally occurring and stress-induced hGR isoforms, as well as the establishment of an hGR-specific database, may reveal new patterns or suggest areas of interest that will lead to the improved understanding of the human stress response system.

Electronic supplementary material

The online version of this article (10.1186/s12863-019-0718-z) contains supplementary material, which is available to authorized users.

Building the Burn Physician Workforce for the 21st Century: Report From February 2014 Burns Workforce Conference

American Burn Association Past President Palmer Q. Bessey, MD, orchestrated a Burn Workforce Conference in Washington, DC in February, 2014, with the goal of evaluating the workforce needs for doctors, nurses, and occupational/physical therapists. This report summarizes the issues related to the need for training future surgeons to manage burn patients. General surgery and plastic surgery residents currently have minimal requirements for burn experience during their training. The respective Boards, however, do require knowledge in the management of burn care. The number of surgeons entering burn fellowships is limited to approximately 10 per year and there are only a handful of burn fellowship programs to train future burn surgeons. A survey sent to burn surgeons revealed that the current workforce is aging and needs to a constant supply of new physicians. It is clear that there is a need to formalize burn fellowships and it was felt that the American Burn Association should be responsible for accreditation of those fellowships.

Timing of Laparotomy and Closure in Burn Patients with Abdominal Compartment Syndrome: Effects on Survival

BACKGROUND

Survival of burn patients with abdominal compartment syndrome (ACS) is uniformly reported to be poor, averaging just 16% after laparotomy. We hypothesize that better outcomes can be achieved with a strategy of immediate laparotomy and early fascial closure.

STUDY DESIGN

Patients with burn injury who were diagnosed with ACS between 2005 and 2016 were identified through a search of databases. Data were gathered from electronic medical records. Timing of laparotomy and closure were calculated for each patient. Patients were stratified into predefined groups based on timing of laparotomy, cause of ACS, patient age, and timing of abdominal closure. Survival rates were calculated and compared.

RESULTS

Forty-six patients with burn injury and ACS were identified. Abdominal compartment syndrome developed during initial resuscitation in 27 patients, during perioperative resuscitation in 5 patients, and during an episode of sepsis in 13 patients. Overall survival was 56%. Mean time to laparotomy from diagnosis of ACS was 1 hour 8 minutes (SD 59 minutes). When ACS developed in patients during initial resuscitation, the mean time to laparotomy from hospital admission was 13 hours (SD 7 hours). Survival rate in this group was 70%, and survival rate in patients treated for ACS later in their hospital course was 33% (p = 0.03). Survival among patients whose laparotomy was closed within 48 hours was 100%, and survival among patients whose laparotomy was not closed within 48 hours was 48% (p = 0.01).

CONCLUSIONS

Immediate laparotomy resulted in much higher survival rates than previously reported in burn patients with ACS. Survival was higher when ACS was diagnosed during initial resuscitation. Fascial closure within 48 hours was associated with improved survival compared with later fascial closure.

Sodium variability is associated with increased mortality in severe burn injury

Background

Dysnatremias are associated with increased mortality in critically ill patients. Hypernatremia in burn patients is also associated with poor survival. Based on these findings, we hypothesized that high plasma sodium variability is a marker for increased mortality in severely burn-injured patients.

Methods

We performed a retrospective review of adult burn patients with a burn injury of 15% total body surface area (TBSA) or greater from 2010 to 2014. All patients included in the study had at least three serum sodium levels checked during admission. We used multivariate logistic regression analysis to determine if hypernatremia, hyponatremia, or sodium variability independently increased the odds ratio (OR) for death.

Results

Two hundred twelve patients met entry criteria. Mean age and %TBSA for the study was 45 ± 18 years and 32 ± 19%. Twenty-nine patients died for a mortality rate of 14%. Serum sodium was measured 10,310 times overall. The median number of serum sodium measurements per patient was 22. Non-survivors were older (59 ± 19 vs. 42 ± 16 years) and suffered from a more severe burn injury (50 ± 25% vs. 29 ± 16%TBSA). While mean sodium was significantly higher for non-survivors (138 ± 3 milliequivalents/liter (meq/l)) than for survivors (135 ± 2 meq/l), mean sodium levels remained within the laboratory reference range (135 to 145 meq/l) for both groups. Non-survivors had a significantly higher median number of hypernatremic (> 145 meq/l) measurements (2 vs. 0). Coefficient of variation (CV) was significantly higher in non-survivors (2.85 ± 1.1) than survivors (2.0 ± 0.7). Adjusting for TBSA, age, ventilator days, and intensive care unit (ICU) stay, a higher CV of sodium measurements was associated with mortality (OR 5.8 (95% confidence interval (CI) 1.5 to 22)). Additionally, large variation in sodium ranges in the first 10 days of admission may be associated with increased mortality (OR 1.35 (95% CI 1.06 to1.7)).

Conclusions

Increased variability in plasma sodium may be associated with death in severely burned patients.

Sepsis in the burn patient: a different problem than sepsis in the general population

Sepsis has recently been defined as "life-threatening organ dysfunction caused by a dysregulated host response to infection". A great amount of effort has been made to develop early treatments for sepsis through the Surviving Sepsis Campaign. There are similar but slightly different recommendations for the treatment of sepsis in the pediatric population. These international efforts have led to earlier diagnosis and treatments for sepsis that have led to improvements in survival. Sepsis is also the leading cause of death in the burn patient but most clinical sepsis studies have excluded burns. The reason for the exclusion is that the sepsis found in burn patients is different than that of the general population. The early treatment strategies, such as those directed by the Surviving Sepsis Campaign, focus on patients presenting to hospitals with recent signs of infection. Burn patients lose their primary barrier to infection, the skin, and thus the risk of infection persists as long as that barrier is absent. Efforts have been made to define sepsis, septic shock and infection in the burn population but there is constant need for revisions. One focus of this review is to discuss the differences in burn sepsis versus sepsis of the general population. Children often have profound responses to sepsis but can also make remarkable recoveries. This review will also explore problems specific to pediatric burns. The treatment of burns requires a continuous vigilance to watch for the subtle early signs of sepsis and then expeditious initiation of aggressive therapy. Strategies covering optimal management of pediatric burn sepsis will also be summarized.

A novel human glucocorticoid receptor SNP results in increased transactivation potential

Glucocorticoids are one of the most widely used therapeutics in the treatment of a variety of inflammatory disorders. However, it is known that there are variable patient responses to glucocorticoid treatment; there are responders and non-responders, or those that need higher dosages. Polymorphisms in the glucocorticoid receptor (GR) have been implicated in this variability. In this study, ninety-seven volunteers were surveyed for polymorphisms in the human GR-alpha (hGRα), the accepted biologically active reference isoform. One isoform identified in our survey, named hGR DL-2, had four single nucleotide polymorphisms (SNPs), one synonymous and three non-synonymous, and a four base pair deletion resulting in a frame shift and early termination to produce a 743 amino acid putative protein. hGR DL-2 had a decrease in transactivation potential of more than 90%. Upon further analysis of the individual SNPs and deletion, one SNP, A829G, which results in a lysine to glutamic acid amino acid change at position 277, was found to increase the transactivation potential of hGR more than eight times the full-length reference. Furthermore, the hGRα-A829G isoform had a differential hyperactive response to various exogenous steroids. Increasing our knowledge as to how various SNPs affect hGR activity may help in understanding the unpredictable patient response to steroid treatment, and is a step towards personalizing patient care.

Inherently variable responses to glucocorticoid stress among endogenous retroviruses isolated from 23 mouse strains

Active participation of endogenous retroviruses (ERVs) in disease processes has been exemplified by the finding that the HERV (human ERV)-W envelope protein is involved in the pathogenesis of multiple sclerosis, an autoimmune disease. We also demonstrated that injury-elicited stressors alter the expression of murine ERVs (MuERVs), both murine leukemia virus-type and mouse mammary tumor virus (MMTV)-type (MMTV-MuERV). In this study, to evaluate MMTV-MuERVs' responses to stress (e.g., injury, infection)-elicited systemic glucocorticoid (GC) levels, we examined the GC-stress response of 64 MMTV-MuERV promoters isolated from the genomes of 23 mouse strains. All 64 promoters responded to treatment with a synthetic GC, dexamethasone (DEX), at a wide range from a 0.6- to 85.7-fold increase in reporter activity compared to no treatment. An analysis of the 10 lowest and 10 highest DEX responders revealed specific promoter elements exclusively present in either the three lowest or the two highest responders. Each promoter had a unique profile of transcription regulatory elements and the glucocorticoid response element (GRE) was identified in all promoters with the number of GREs ranging from 2 to 7. The three lowest DEX responders were the only promoters with two GREs. The findings from this study suggest that certain MMTV-MuERVs are more responsive to stress-elicited systemic GC elevation compared to the others. The mouse strain-specific genomic MMTV-MuERV profiles and individual MMTV-MuERVs' differential responses to GC-stress might explain, at least in part, the variable inflammatory responses to injury and/or infection, often observed among different mouse strains. This article is part of a Special Issue entitled: Immune and Metabolic Alterations in Trauma and Sepsis edited by Dr. Raghavan Raju.

A competing risk analysis for hospital length of stay in patients with burns

IMPORTANCE

Current outcome predictors for illness and injury are measured at a single time point-admission. However, patient prognosis often changes during hospitalization, limiting the usefulness of those predictions. Accurate depiction of the dynamic interaction between competing events during hospitalization may enable real-time outcome assessment.

OBJECTIVE

To determine how the effects of burn outcome predictors (ie, age, total body surface area burn, and inhalation injury) and the outcomes of interest (ie, mortality and length of stay) vary as a function of time throughout hospitalization.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective study, we used the American Burn Association's National Burn Repository, containing outcomes and patient and injury characteristics, to identify 95 579 patients admitted with an acute burn injury to 80 tertiary American Burn Association burn centers from 2000 through 2009. We applied competing risk statistical methods to analyze patient outcomes.

MAIN OUTCOMES AND MEASURES

We estimated the cause-specific hazard rates for death and discharge to assess how the instantaneous risk of these events changed across time. We further evaluated the varying effects of patient age, total body surface area burn, and inhalation injury on the probability of discharge and death across time.

RESULTS

Maximum length of stay among patients who died was 270 days and 731 days among those discharged. Total body surface area, age, and inhalation injury had significant effects on the subdistribution hazard for discharge (P < .001); these effects varied across time (P < .002). Burn size (coefficient -0.046) determined early outcomes, while age (coefficient -0.034) determined outcomes later in the hospitalization. Inhalation injury (coefficient -0.622) played a variable role in survival and hospital length of stay.

CONCLUSIONS AND RELEVANCE

Real-time measurement of dynamic interrelationships among burn outcome predictors using competing risk analysis demonstrated that the key factors influencing outcomes differed throughout hospitalization. Further application of this analytic technique to other injury or illness types may improve assessment of outcomes.

Predicting mortality from burns: the need for age-group specific models

Traditional burn mortality models are derived using all age groups. We hypothesized that age variably impacts mortality after burn and that age-specific models for children, adults, and seniors will more accurately predict mortality than an all-ages model. We audited data from the American Burn Association (ABA) National Burn Repository (NBR) from 2000 to 2009 and used mixed effect logistic regression models to assess the influence of age, total body surface area (TBSA) burn, and inhalation injury on mortality. Mortality models were constructed for all ages and age-specific models: children (<18 years), adults (18-60 years), and seniors (>60 years). Model performance was assessed by area under the receiver operating curve (AUC). Main effect and two-way interactions were used to construct age-group specific mortality models. Each age-specific model was compared to the All Ages model. Of 286,293 records 100,051 had complete data. Overall mortality was 4% but varied by age (17% seniors, <1% children). Age, TBSA, and inhalation injury were significant mortality predictors for all models (p<0.05). Differences in predicted mortality between the All Ages model and the age-specific models occurred in children and seniors. In the age-specific pediatric model, predicted mortality decreased with age; inhalation injury had greater effect on mortality than in the All Ages model. In the senior model mortality increased with age. Seniors had greater increase in mortality per 1% increment in burn size and 1 year increase in age than other ages. The predicted mortality in seniors using the senior-specific model was higher than in the All Ages model. "One size fits all" models for predicting burn outcomes do not accurately reflect the outcomes for seniors and children. Age-specific models for children and seniors may be advisable.

Redefining the outcomes to resources ratio for burn patient triage in a mass casualty

Recent disasters highlight the need for predisaster planning, including the need for accurate triage. Data-driven triage tables, such as that generated from the 2002 National Burn Repository, are vital to optimize resource use during a disaster. The study purpose was to generate a burn resource disaster triage table based on current burn-treatment outcomes. Data from the NBR after the year 2000 were audited. Records that missed age, burn size, or survival status were excluded from analysis. Duplicate records, readmissions, transfers, and nonburn injuries were eliminated. Resource use was divided into expectant (predicted mortality >90%), low (mortality 50-90%), medium (mortality 10-50%), high (mortality <10%, admission 14-21 days), very high (mortality <10%, admission <14 days), and outpatient. Tables were created for all patient admissions and with/without inhalation injury. Of the 286,293 records, 210,683 were from the year 2000 or later. Expectant status for those aged >70 years began at 50% burn; a 20- to 29-year-old never reached expectant status. Inhalation injury lowered the expectant category to a burn size of 40% in >70-year-olds, and at >90% in 20- to 29-year-olds. The 0- to 1.9-year old group without inhalation injury never reached expectant status; with inhalation injury, expectant status was reached at >80% burn. Changes in the triage tables suggest that burn care has changed in the past 10 years. Inhalation injury significantly alters triage in a burn disaster. Use of these updated tables for triage in a disaster may improve our ability to allocate resources.

A ten-year review of lower extremity burns in diabetics: small burns that lead to major problems

Diabetes mellitus with its resulting neurovascular changes may lead to an increased risk of burns and impaired wound healing. The purpose of this article is to review 10 years of experience with foot and lower leg burns in patients with diabetes at a single adult burn center. Patients with lower extremity burns and diabetes mellitus, between May 1999 and December 2009, were identified in the Trauma Registry of the American College of Surgeons database, and their charts were reviewed for data related to their outcomes. Sixty-eight diabetic patients, 87% male, with a mean age of 54 years, sustained foot or lower extremity burns with 37 having burns resulting from insensate feet. The pathogenesis included walking on a hot or very cold surface (8), soaking feet in hot water (22), warming feet on or near something hot such as a heater (13), or spilling hot water (7). The majority of patients were taking insulin (59.6%) or oral hyperglycemic medications (34.6%). Blood sugar levels were not well controlled (mean glucose, 215.8 mg/dl; mean hemoglobin A1c, 9.08%). Renal disease was common with admission serum blood urea nitrogen (27.5 mg/dl) and creatinine (2.21 mg/dl), and 13 were on dialysis preinjury. Cardiovascular problems were common with 39 (57%) having hypertension or cardiac disease, 3 having peripheral vascular disease, and 9, previous amputations. The mean burn size was 4.2% TBSA (range, 0.5-15%) with 57% being full thickness. Despite the small burn, the mean length of stay was 15.2 days (range, 1-95), with 5.65 days per 1% TBSA. Inability to heal these wounds was evident in 19 patients requiring readmission (one required 10 operative procedures). At least one patient sustained more than one burn. There were 62 complications with 30 episodes of infection (cellulitis, 28; osteomyelitis, 4; deep plantar infections, 2; ruptured Achilles tendon, 1) and 3 deaths. Eleven patients needed amputations (7 below-knee amputations, 4 transmetatarsal amputations, and 20 toe amputations) with several needing revisions or higher amputations. Patients with diabetes have an increased risk for lower extremity complications, but the risk of burns is not well known. The majority of lower extremity burns result from intentional exposure to sources of heat without recognition for the risk of burns. Once a burn occurs, morbidity and cost to the patient and society are severe. Prevention programs should be initiated to make diabetic patients and their doctors aware of the significant risk for burns.

Identification of a group of Mus dunni endogenous virus-like endogenous retroviruses from the C57BL/6J mouse genome: proviral genomes, strain distribution, expression characteristics, and genomic integration profile

About 10 % of the mouse genome is occupied by sequences associated with endogenous retroviruses (ERVs). However, a comprehensive profile of the mouse ERVs and related elements has not been established yet. In this study, we identified a group of ERVs from the mouse genome and characterized their biological properties. Using a custom ERV mining protocol, 191 ERVs (159 loci reported previously and 32 new loci), tentatively named Mus dunni endogenous virus (MDEV)-like ERVs (MDL-ERVs), were mapped on the C57BL/6J mouse genome. Seven of them retained putative full coding potentials for three retroviral polypeptides (gag, pol, and env). Among the 57 mouse strains examined, all but the Mus pahari/Ei strain had PCR amplicons corresponding to a conserved MDL-ERV region. Interestingly, the Mus caroli/EiJ's amplicon was somewhat larger than the others, coinciding with a substantial phylogenetic distance between the MDL-ERV populations of M. caroli/EiJ and C57BL/6J strains. MDL-ERVs were highly expressed in the lung, spleen, and thymus of C57BL/6J mice compared to the brain, heart, kidney, and liver. Seven MDL-ERVs were mapped in the introns of six annotated genes. Of interest, some MDL-ERVs were mapped periodically on three clusters in chromosome X. The finding that these MDL-ERVs were one of several types of retroelements, which form mosaic-repeat units of tandem arrays, suggests that the formation of the mosaic-repeat unit preceded the tandem arrangement event. Further studies are warranted to understand the biological roles of MDL-ERVs in both normal and pathologic conditions.

ERE database: a database of genomic maps and biological properties of endogenous retroviral elements in the C57BL/6J mouse genome

Endogenous retroviral elements (EREs), a family of transposable elements, constitute a substantial fraction of mammalian genomes. It is expected that profiles of the ERE sequences and their genomic locations are unique for each individual. Comprehensive characterization of the EREs' genomic locations and their biological properties is essential for understanding their roles in the pathophysiology of the host. In this study, we identified and mapped putative EREs (a total of 111 endogenous retroviruses [ERVs] and 488 solo long terminal repeats [sLTRs]) within the C57BL/6J mouse genome. The biological properties of individual ERE isolates (both ERVs and sLTRs) were then characterized in the following aspects: transcription potential, tropism trait, coding potential, recombination event, integration age, and primer binding site for replication. In addition, a suite of database management system programs was developed to organize and update the data acquired from current and future studies and to make the data accessible via internet.