Refining the referral criteria of persons who have been burned to palliative care: A modified Delphi approach.

A paucity of evidence is available to guide integration of specialist palliative care into burn care. This study's purpose was to develop consensus on referral criteria using a modified Delphi process. Content experts were defined as burn or palliative care providers in locations where the teams have collaborative history; published at least one manuscript or presented nationally on burn and palliative care collaboration; or nomination as having equivalent expertise. N = 202 eligible persons were identified; n = 43 participated in Iteration 1 and Iteration 3 retained 79%. Iteration 1 invited participants to rank published referral criteria on a 9-point Likert-style scale. Consensus was defined as an interquartile range ≤ 2. Consensus items with median scores ≤ 3 were dropped from further consideration. Consensus items with median scores ≥ 7 were considered to be important and excluded in Iteration 2. Iteration 2 which presented non-consensus items with their associated median (interquartile range) and the participant's own ranking from Iteration 1. Iteration 3 presented three models; participants ranked in order of preference and suggested revisions. Consensus was achieved on a final set of criteria for specialist palliative care for persons who sustain burn injuries. Future research should prospectively evaluate the criteria against meaningful outcomes.

Comparing novel virtual reality and nursing standard care on burn wound care pain in adolescents: A randomized controlled trial.

PURPOSE: This study compared the effectiveness of age-appropriate, high technology, interactive virtual reality (VR) distraction with standard care (SC) provided by the nurse on adolescents' acute procedural pain intensity perception during burn wound care treatment in the ambulatory clinic setting. DESIGN: This randomized controlled trial included 43 adolescents ages 10-21 from the ambulatory burn clinic of a large children's hospital. METHODS: Blinded study participants were randomly assigned to either VR or SC (non-significantly different, current mean burn surface area, 1.3 and 1.7, respectively) during the first burn wound care procedure in the burn clinic. Blinded research staff collected pre-procedure data including Spielberger's State-Trait Anxiety Inventory and postprocedure wound care pain intensity using the Adolescent Pediatric Pain Tool. A total of 41 participants completed all study procedures. RESULTS: No statistically significant difference in burn wound care procedural pain was noted between the VR and SC groups after adjusting for several factors. Pre-procedure state and trait anxiety correlated with reported pre-procedure pain. Wound care pain was found to be significantly associated with pre-wound care pain score, time from original burn to clinic burn care treatment, and length of wound care treatment. These factors accounted for approximately 45% of the variation in pain scores during wound care treatment. PRACTICE IMPLICATIONS: VR distraction can be a useful pain management strategy but may not take the place of the unique nurse-patient relationship that occurs during clinical encounters. Tailoring pain management during burn wound care requires consideration of anxiety, time from the burn injury to the wound care procedure, length of time of the wound care procedure, and pretreatment pain level. Knowing patients' needs, desires, and temperaments along with the specifics about the healthcare procedures are critical to formulating individualized care plans that may or may not include VR. Newer technology, such as easier-to-use, less expensive VR, may assist with translation into practice making its clinical use more routine.

Integrating Palliative Care into Burn Care: A Retrospective Application of Criteria for Appropriate Referral.

Burn injuries often require complex interdisciplinary care. Despite potential benefits, consultation with specialist palliative care typically occurs in 2% of burn admissions, due largely to lack of availability and misconceptions concerning palliative care. Criteria to guide consultation with specialist palliative care have been developed at this institution. The purpose of this study was to quantify the sensitivity and specificity of these criteria, and then optimize them. Retrospective examination of 388 admissions over 15 months at this adult and pediatric Burn Center were conducted. Chi-square or Fisher's exact test for categorical variables and Wilcoxon Rank Sum test for continuous variables were used to test for between-group differences in demographic and clinical characteristics. Logistic regression model was built to determine modified Baux cut-off score using Youden index (J) value. Criteria were sensitive (0.96) and specific (0.90), though with a low positive predictive value (0.43). Persons with lengths of stay greater than one week, advanced directives, Allow Natural Death orders, and/or deterioration events were significantly more likely to have had palliative care consulted. There were significant between-group differences (with/without palliative care consultation) based on burn surface area, modified Baux score, and mortality risk. Potential criteria revisions are proposed. Prospective adherence to revised criteria could provide useful guidance to providers and benefit to patients and families.

Palliative Care and Burn Care: Empirically Derived Referral Criteria.

Burns frequently require complex interdisciplinary care. Specialist palliative care (PC) minimizes suffering, aids in decision making, and provides family support in addition to end-of-life care. Specialist PC is a limited resource, best conserved by identifying persons most likely to benefit from a PC referral. Little guidance is available for clinicians on whether and when to refer to PC. This study's purpose was to identify referral criteria using a mixed-methods approach. Data were examined for between-group differences using Fisher's exact, chi-square, or Wilcoxon Rank Sum tests. Qualitative thematic analysis was used to analyze PC provider notes to describe interventions provided. These data formed initial referral criteria, which were reviewed by an expert panel. Significant between-group differences included dying in the burn center; whether multiple patients were transported to the burn center from one event; and ventilator days. Four themes emerged from qualitative analysis. These included managing physical aspects of care; clarifying goals of care; managing end-of-life care; and managing patient/family psychosocial distress. Expert panel input clarified referral criteria language and supplemented the proposed criteria. We present empirically derived referral criteria to guide burn providers in referring persons for specialist PC. Subsequent testing is required to determine their efficacy in improving patient/family outcomes.

Lessons Learned From the Creation of a Business of Medicine Course.

This article was migrated. The article was marked as recommended. Knowledge, attitudes, and skills required to successfully manage business and personal finances are rarely taught within traditional medical education. This has contributed to low financial literacy, high stress related to educational debt, and burnout among physicians. To address this deficiency, we created the Business of Medicine course for fourth-year medical students which teaches basic business and personal finance topics. As we have reflected on lessons learned in the creation and implementation of this course, we have recorded them for the benefit of others who desire to partner with us in teaching this important topic to the next generation of physicians.

Butane Hash Oil Burns: A 7-Year Perspective on a Growing Problem.

With the legalization of marijuana in four states, and decriminalization in many others, marijuana is becoming easier to obtain. The authors have experienced an increase in burn injuries related to the production of butane hash oil (BHO; a concentrated tetrahydrocannabinol product produced by the distillation of marijuana plant products with pressurized butane). This article updates our experience and highlights the increasing public health problem associated with these burns. Charts of patients who presented to the burn center with suspicion of BHO-related injuries between January 2007 and December 2014 were examined. Data collected included demographics, injury characteristics, treatment utilized, and outcomes. Charts of 101 patients were identified as having BHO-related burn injury. The mean age of these patients was 30.5 ± 10.6 years (mean ± standard deviation, range: 2-55 years) and 93.1% were male. Patients sustained a mean of 26.8 ± 24.1% TBSA burn with 14.3 ± 25.1% third degree burns. Three patients died as the result of their injuries. Patients required a mean of 12 ± 48.4 ventilator days, and 27.1 ± 59.4 days in the hospital. The number of patients presenting with these burns increased over the past 7 years. BHO burns occur most commonly in February (12 patients), on Wednesday (19 patients), and between 18:00 and 06:00 (58 patients). There has been a sharp increase in the number of patients presenting with burn-associated BHO production in the region over the past 7 years. The authors as burn care providers need to increase public awareness of this issue and aid in the development of legislation to help prevent these burns before it becomes a public health crisis.

Acellular human dermis implantation in 153 immediate two-stage tissue expander breast reconstructions: determining the incidence and significant predictors of complications.

BACKGROUND: Little information exists on the incidence of complications after acellular human dermis implantation in two-stage tissue expander breast reconstruction. The purpose of this study was to evaluate the incidence of postoperative adverse events and identify significant predictors of complications in acellular human dermis tissue expander breast reconstruction. METHODS: This study accrued all patients from January of 2004 through April of 2008 undergoing two-stage immediate tissue expander breast reconstruction using acellular human dermis. A total of 153 expanders were placed. Complications were assessed. Univariate and multivariate logistic regression modeling was performed. Comparison of complication rates using the traditional (non-acellular human dermis) technique from concurrent (2004 to 2008) and consecutive time periods (2001 to 2003) for 2910 and 1170 expanders, respectively, is provided. RESULTS: A total of 153 expanders were implanted in 96 women: 39 unilateral and 57 bilateral. Eleven (7.2 percent) were removed due to infection (n = 5, 3.3 percent), exposure (n = 4, 2.6 percent), or patient preference (n = 2, 1.3 percent). Other complications included cellulitis (3.9 percent), seroma (7.2 percent), hematoma (2.0 percent), mastectomy flap necrosis (4.6 percent), and leak/failed expansion (0.0 percent); 92.8 percent were successfully expanded and exchanged for a permanent implant. Eleven seromas (7.2 percent) were identified; nine underwent aspiration. None of these resulted in infection or reconstructive failure. Univariate analysis revealed age, body mass index, axillary dissection, and postoperative chemotherapy to be associated with reconstructive failure (p < 0.05). Multivariate analysis revealed that age, body mass index, and axillary dissection are independent risk factors for developing complications (p < 0.05). CONCLUSION: Acellular human dermis is a useful adjunct for intraoperative pocket development in immediate tissue expander reconstruction but can result in an increased risk of complications, in particular, seroma and reconstructive failure.

The absorbable dermal staple device: a faster, more cost-effective method for incisional closure.

BACKGROUND: Closure with dermal sutures is time consuming, may increase the risks of inflammation and infection secondary to foreign body reaction, exposes the surgeon to possible needlestick injuries, and has variable cosmetic outcomes depending on each surgeon's technique. The absorbable INSORB dermal stapler is hypothesized to be faster and more cost effective than sutures for dermal layer closures and provides a safer and more consistent result. METHODS: This is a prospective, randomized, controlled study. Patients undergoing bilateral breast reconstruction with tissue expanders had one incision randomized to dermal closure with absorbable dermal staples. The contralateral side was closed with dermal sutures. During the expansion period, wounds were assessed by a blinded plastic surgeon using the 13-point Vancouver Scar Scale. At the time of implant exchange, both scars were excised and examined for histologic signs of inflammation. RESULTS: Eleven patients (22 incisions) were enrolled in the study. The dermal stapler was four times faster than standard suture closure, reducing closure time by 10.5 minutes (p

Gene therapy in skin: choosing the optimal viral vector.

Skin is an ideal gene therapy target because it is readily accessible and is involved in many pathologic processes. Viruses are the most common gene vectors, however, few comparative studies exist examining their efficacy in skin. This study evaluates adenovirus serotype 5, adeno-associated virus type 2 and 5, MMLV-derived retrovirus, and human immunodeficiency virus-1 derived lentivirus for gene vector activity in human dermal fibroblasts and other skin cell lines. Human immunodeficiency virus-1-based lentiviral vector resulted in over 90% transduction in all cell lines tested. Transduced cells maintained reporter expression over several passages after a single exposure. In contrast, gene activity fell rapidly over cell divisions with adenoviral and adeno-associated vectors. Therefore, lentiviral vectors are the delivery mechanism of choice for long-term therapeutic gene expression in dermal fibroblasts and other skin cell lines, whereas adenoviral or adeno-associated vectors may be preferred for short-term therapy.

A novel method for targeted gene therapy in ischemic tissues through viral transfection of an expression cassette containing multiple repetitions of hypoxia response element.

BACKGROUND: Increased levels of the transcription factor hypoxia inducible factor (HIF)-1 occur only in hypoxic tissue. The authors propose a therapeutic strategy that relies on HIF-1, the enhancer hypoxia response element (HRE), and the delivery vector adeno-associated virus-2 (AAV2) to direct ischemia specific gene therapy to skin. METHODS: An expression cassette containing the CMV promoter driving the reporter gene green fluorescent protein (GFP) was used to assess cutaneous tropism of AAV2. Transfection of dermal fibroblasts and immortalized keratinocytes (HaCat) was assessed with flow cytometry. Human embryonic kidney 293 (HEK) cells were used to produce vector stocks and test the authors' therapeutic strategy in quadruplicate. An expression cassette with nine repeats of HRE linked to beta-galactosidase (LacZ) within the AAV2 vector was constructed. HEK cells were transfected and exposed to normoxic (21% oxygen) and hypoxic (1% oxygen) conditions. LacZ activity was measured by conversion of galactoside red-beta-D-galactopyranoside. RESULTS: Approximately 50 percent of dermal fibroblasts and HaCat cells were transfected when treated with 1 x 10(4) genome copies/cell of AAV2-CMV-GFP. Using the same titration of AAV2-9HRE-LacZ, transfected HEK cells demonstrated LacZ activity of 0.496 +/- 0.068 U/microg in normoxia and 2.9 +/- 0.58 U/microg in hypoxia. Transfected cells exposed to 24 hours of hypoxia show greater than an 11-fold increase in LacZ activity (p < 0.05) compared with baseline normoxic controls. CONCLUSIONS: The authors' results confirm that AAV2 has in vitro tropism for skin-derived cell lines. Furthermore, HRE will drive gene expression in ischemia but not normoxia. This is the first step toward the authors' goal of HIF-1-regulated gene therapy to prevent ischemia related skin injury.

Entry inhibitor-based microbicides are active in vitro against HIV-1 isolates from multiple genetic subtypes.

Inhibitors of viral entry are under consideration as topical microbicides to prevent HIV-1 sexual transmission. Small molecules targeting HIV-1 gp120 (BMS-378806) or CCR5 (CMPD167), and a peptide fusion inhibitor (C52L), each blocks vaginal infection of macaques by a SHIV. A microbicide, however, must be active against multiple HIV-1 variants. We therefore tested BMS-C (a BMS-378806 derivative), CMPD167, C52L and the CXCR4 ligand AMD3465, alone and in combination, against 25 primary R5, 12 X4 and 7 R5X4 isolates from subtypes A-G. At high concentrations (0.1-1 microM), the replication of most R5 isolates in human donor lymphocytes was inhibited by >90%. At lower concentrations, double and triple combinations were more effective than individual inhibitors. Similar results were obtained with X4 viruses when AMD3465 was substituted for CMPD167. The R5X4 viruses were inhibited by combining AMD3465 with CMPD167, or by the coreceptor-independent compounds. Thus, combining entry inhibitors may improve microbicide effectiveness.

Rapid upregulation of alpha7 nicotinic acetylcholine receptors by tyrosine dephosphorylation.

Alpha7 nicotinic acetylcholine receptors (nAChRs) modulate network activity in the CNS. Thus, functional regulation of alpha7 nAChRs could influence the flow of information through various brain nuclei. It is hypothesized here that these receptors are amenable to modulation by tyrosine phosphorylation. In both Xenopus oocytes and rat hippocampal interneurons, brief exposure to a broad-spectrum protein tyrosine kinase inhibitor, genistein, specifically and reversibly potentiated alpha7 nAChR-mediated responses, whereas a protein tyrosine phosphatase inhibitor, pervanadate, caused depression. Potentiation was associated with an increased expression of surface alpha7 subunits and was not accompanied by detectable changes in receptor open probability, implying that the increased function results from an increased number of alpha7 nAChRs. Soluble N-ethylmaleimide-sensitive factor attachment protein receptor-mediated exocytosis was shown to be a plausible mechanism for the rapid delivery of additional alpha7 nAChRs to the plasma membrane. Direct phosphorylation/dephosphorylation of alpha7 subunits was unlikely because mutation of all three cytoplasmic tyrosine residues did not prevent the genistein-mediated facilitation. Overall, these data are consistent with the hypothesis that the number of functional cell surface alpha7 nAChRs is controlled indirectly via processes involving tyrosine phosphorylation.