Effective and durable repigmentation for stable vitiligo: A randomized within-subject controlled trial assessing treatment with autologous skin cell suspension transplantation.

BACKGROUND: Vitiligo lesions are often challenging to repigment with conventional medical therapies. Surgical autologous melanocyte transfer methods can be utilized for stable vitiligo but demand specialized skills and equipment. A point-of-care autologous cell harvesting device was designed enabling simple preparation of autologous skin cell suspension (ASCS) containing melanocytes, keratinocytes, and fibroblasts providing a straightforward approach for cellular transplantation. OBJECTIVE: To evaluate the safety and effectiveness of ASCS for repigmentation of stable vitiligo lesions among adults. METHODS: A US multicenter, randomized, within-subject controlled trial compared ASCS to narrow band ultraviolet B only (Control) in similar vitiligo lesions. ASCS was applied after laser skin resurfacing and followed by narrow band ultraviolet B treatment. The primary effectiveness endpoint was the proportion of lesions achieving ≥80% repigmentation at week-24. Repigmentation durability was assessed at week-52. RESULTS: Among 25 subjects, 36% of ASCS-treated lesions achieved ≥80% repigmentation at week-24 compared to 0% for Control (P < .025), with durability through week-52. The safety profile of ASCS was acceptable, with favorable patient- and investigator-reported outcomes. LIMITATIONS: Study sample size limited robust subgroup analyses. CONCLUSION: Application of ASCS has potential as a treatment for repigmentation of stable vitiligo lesions with the potential to improve health-related quality of life and reduce burden of disease.

Autologous Skin Cell Suspension for Full-Thickness Skin Defect Reconstruction: Current Evidence and Health Economic Expectations.

Despite differing etiologies, acute thermal burn injuries and full-thickness (FT) skin defects are associated with similar therapeutic challenges. When not amenable to primary or secondary closure, the conventional standard of care (SoC) treatment for these wound types is split-thickness skin grafting (STSG). This invasive procedure requires adequate availability of donor skin and is associated with donor site morbidity, high healthcare resource use (HCRU), and costs related to prolonged hospitalization. As such, treatment options that can facilitate effective healing and donor skin sparing have been highly anticipated. The RECELL® Autologous Cell Harvesting Device facilitates preparation of an autologous skin cell suspension (ASCS) for the treatment of acute thermal burns and FT skin defects. In initial clinical trials, the approach showed superior donor skin-sparing benefits and comparable wound healing to SoC STSG among patients with acute thermal burn injuries. These findings led to approval of RECELL for this indication by the US Food and Drug Administration (FDA) in 2018. Subsequent clinical evaluation in non-thermal FT skin wounds showed that RECELL, when used in combination with widely meshed STSG, provides donor skin-sparing advantages and comparable healing outcomes compared with SoC STSG. As a result, the device received FDA approval in June of 2023 for treatment of FT skin defects caused by traumatic avulsion or surgical excision or resection. Given that health economic advantages have been demonstrated for RECELL ± STSG versus STSG alone when used for burn therapy, it is prudent to examine similarities in the burn and FT skin defect treatment pathways to forecast the potential health economic advantages for RECELL when used in FT skin defects. This article discusses the parallels between the two indications, the clinical outcomes reported for RECELL, and the HCRU and cost benefits that may be anticipated with use of the device for non-thermal FT skin defects.

A retrospective analysis of mortality risk and immunosuppressive therapy for Stevens-Johnson Syndrome and toxic epidermal necrolysis syndrome using the TriNetX research network.

Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) exist on a spectrum of autoimmune conditions which cause epidermal detachment and keratinocyte necrosis. Due to the rare incidence of these conditions, a dramatic heterogeneity in treatment algorithms exists. To better appreciate pharmacologic immunosuppressive therapies' impact on survival, the authors queried a multi-institutional data network. Data for this study was extracted from TriNetX Research Network, a platform that contains ICD-9/ICD-10 coding data from a consortium of international healthcare organizations. Seventy-one institutions were queried to identify adult patients diagnosed with SJS, TEN or SJS-TEN Overlap. Cohorts were created based on the therapy received: systemic steroids (SS), diphenhydramine (DH), cyclosporine (CS), intravenous immunoglobulin (IVIG), tumor necrosis factor alpha inhibitors (TNFαi), or a combination of treatments. Cohorts were then propensity matched with patients who received supportive care. Patients who only received one of the above treatments showed no significant reduction in 90-day mortality. Patients who received CS or IVIG as part of their multitherapy showed a significantly increased risk of death when compared to supportive care (CS: RR = 1.583, 95% CI [1.119, 2.240]; IVIG: RR = 2.132, 95% CI [1.485, 3.059]). Despite their frequent utilization, this study's analysis suggests that none of these therapies confer significant 90-day mortality survival over supportive care alone. These results highlight the heterogeneity of therapies and emphasize the need for critical prospective appraisal of their outcomes in SJS and TEN.

Burn Injury From Smoking Electronic Cigarettes While on Supplemental Oxygen.

Many reports pertaining to burns from e-cigarette battery explosions exist, as do injuries from smoking conventional cigarettes while on home-oxygen therapy. However, literature regarding burn injuries from e-cigarettes while on oxygen therapy is limited. The heating coil of the device can rise to temperatures that facilitates ignition of oxygen. The purpose of this study is to describe and characterize this novel and under-reported mechanism of injury. This study was a descriptive review of 2013-2016 National Burn Repository (NBR) data, with a query for "oxygen," "O2," "electronic cigarettes," and various permutations/abbreviations/misspellings. Demographics, injury characteristics, and outcomes were reported. Also, a Google search for lay-press articles and a PubMed/Scopus search using similar terms was conducted to find literature. Of approximately 60,000 NBR entries, 8 records of injury while smoking e-cigarettes on oxygen were found. Patients were predominantly male, 63 ± 9 years old, with 3.4% ± 4 TBSA burns, and LOS of 5.8 ± 7 days (an LOS O/E ratio of 1.5). Two patients sustained full-thickness burns (0.5% and 11% TBSA). Three were intubated, with mean of 3.33 ventilator-days. Most injuries occurred at home (88%). All patients survived. A google search revealed five lay-press articles. Only three partially relevant scientific articles were found to only mention the phenomenon, without granular data. Although uncommon, smoking e-cigarettes on supplemental oxygen can result in injury without a lithium-ion battery explosion. Limitations in the database may have resulted in underestimation of injuries. A paucity of relevant literature exists, necessitating more research. Patients who receive home-O2 should be warned about this potential danger.

Cost impact of hydroxocobalamin in the treatment of patients with known or suspected cyanide poisoning due to smoke inhalation from closed-space fires.

BACKGROUND & OBJECTIVES: Cyanide poisoning can occur due to exposure to smoke in closed-space fires. With no point of care cyanide test at the scene of a fire, first responders and clinicians base decisions to treat with cyanide antidote on patient history, clinical signs, and other indirect data points that have not been proven to correspond with actual systemic levels of cyanide. The aim of this exploratory study was to determine the economic implications of treating patients with known or suspected cyanide poisoning due to smoke inhalation with hydroxocobalamin. METHODS: A decision analysis model was developed from the US hospital perspective. Healthcare resource utilization was estimated from a retrospective evaluation of clinical outcomes in hydroxocobalamin-treated patients and in historical controls without hydroxocobalamin use (Nguyen, et al. 2017). Epidemiologic parameters and costs were estimated from the published literature, and publicly-available hospital charges were identified. Outcomes reported in the analysis included expected healthcare resource utilization in the US population and per-patient costs with and without the use of hydroxocobalamin. A cost-to-charge ratio was applied so that all costs would reflect hospital costs rather than hospital charges. Deterministic sensitivity analysis was performed to identify the most influential model parameters. All costs were reported in 2017 US dollars. RESULTS: Use of hydroxocobalamin reduces healthcare resource utilization and contributes to decreased per-patient hospital costs ($15,381 with hydroxocobalamin treatment versus $22,607 with no cyanide antidote). The most substantive cost-savings resulted from decreased hospital length of stay (i.e., intensive care unit [ICU] and non-ICU). Costs attributed to mechanical ventilation also decreased with use of hydroxocobalamin. A univariate sensitivity analysis demonstrated that the most impactful variables in the cost analysis were related to hospital length of stay (ICU followed by non-ICU stay), followed by the daily cost of ICU stay. CONCLUSIONS: Use of hydroxocobalamin in patients with known or suspected cyanide poisoning from closed-space fire smoke inhalation may decrease hospital costs and contribute to more efficient healthcare resource utilization.

Nebulized Heparin With N-Acetylcysteine and Albuterol Reduces Duration of Mechanical Ventilation in Patients With Inhalation Injury.

OBJECTIVE: Nebulized heparin has been proposed to improve pulmonary function in patients with inhalation injuries. The purpose of this study was to evaluate the impact of nebulized heparin with N-acetylcysteine (NAC) and albuterol on the duration of mechanical ventilation in burn patients. METHODS: This is a retrospective study evaluating mechanically ventilated adult patients admitted to a regional burn center with inhalation injury. Outcomes were compared between patients who were prescribed a combination of nebulized heparin with NAC and albuterol versus similar patients who did not. RESULTS: A total of 48 patients met inclusion criteria (heparin n = 22; nonheparin n = 26). Patients in the nonheparin group had higher percentage of total body surface area (TBSA) burned (29.00 [5.75-51.88] vs 5.25 [0.50-13.25] %TBSA; P = .009), longer duration of mechanical ventilation (6.50 [2.75-17.00] vs 3.00 [1.00-8.25] days; P = .022), and longer intensive care unit length of stay (LOS) (3.00 [3.00-28.75] vs 5.50 days [2.00-11.25]; P = .033). Upon regression, use of heparin was the only variable associated with reducing the duration of mechanical ventilation ( P = .039). CONCLUSION: Nebulized heparin in combination with NAC and albuterol was associated with a significant reduction in the duration of mechanical ventilation.

Determining the role of nasolaryngoscopy in the initial evaluation for upper airway injury in patients with facial burns.

BACKGROUND: Upper airway injuries can be fatal in burn patients if not recognized, a scenario that causes a significant amount of anxiety for physicians providing initial assessment of burn patients. Early elective intubation is often performed; sometimes unnecessarily. However, some providers employ nasolaryngoscopy for patients presenting with facial burns or signs/symptoms of upper airway injury in order to assess the need for intubation, but this practice is not considered standard of care and may also be unnecessary. Evidence is currently lacking about the utility of nasolaryngoscopy as an adjuvant assessment during evaluation of potential upper airway burn injuries. The objective of this study was to determine if nasolaryngoscopy provides additional information to the history and physical in making the decision to electively intubate patients with facial burns. METHODS: This study was a retrospective analysis of all patients who underwent fiberoptic nasolaryngoscopy after facial burn injury to evaluate for upper airway injury associated with burns over a 2 year period at a regional burn center. During this time period, all patients who presented with facial burns, soot, or carbonaceous sputum underwent nasolaryngoscopy to look for upper airway injury regardless of mechanism of injury. Patients intubated prior to arrival were excluded from the study. Patients were considered to have signs/symptoms of airway injury (symptomatic) if they presented with dyspnea, tachypnea, hypoxia, or significant burns to buccal mucosa. Procedure notes were used to determine if supraglottic/glottic injury (erythema or edema) was present on nasolaryngoscopy. Presence of pathologic changes and whether they led to intubation were evaluated in the asymptomatic and the symptomatic groups of patients. Select individual records were inspected further to help determine if the nasolaryngoscopy findings altered management plans and if intubation was ultimately necessary based upon the presence or absence of a cuff leak and the duration of intubation. RESULTS: Twenty-two patients were symptomatic upon presentation, 14 of which had positive findings on laryngoscopy and 7 (50%) were intubated. One-hundred and eighty-eight patients were asymptomatic, 58 (31%) of which had either erythema or edema or carbonaceous debris on nasolaryngoscopy, and only 2 (1%) were intubated. These patients were both extubated within two days. None of the 130 asymptomatic patients with negative nasolaryngoscopy were intubated. CONCLUSIONS: This study showed disparity between signs and symptoms of airway injury and nasolaryngoscopy findings. Asymptomatic patients showed pathologic changes in 30% of scopes, but this finding only changed management 1% of the time. Furthermore, the two patients in this group were extubated quickly, suggesting they may have been suitable for observation without intubation. These results indicate that the presence of erythema or edema is of questionable clinical significance in asymptomatic patients and nasolaryngoscopy is of limited benefit in this group. Only 50% of the symptomatic patients with airway injury evident on nasolaryngoscopy were actually intubated, also bringing into question the significance of the pathologic changes in this group. However, negative nasolaryngoscopy may have had some benefit in preventing intubation in a few, select symptomatic patients. This study suggests that a thorough history and physical is the best tool to identify patients at higher risk of upper airway injury who need intubation, but this should be further studied in prospective trials to determine the definitive role of nasolaryngoscopy.

A Novel Classification System for Injuries After Electronic Cigarette Explosions.

Electronic cigarettes (e-cigarettes) contain lithium batteries that have been known to explode and/or cause fires that have resulted in burn injury. The purpose of this article is to present a case study, review injuries caused by e-cigarettes, and present a novel classification system from the newly emerging patterns of burns. A case study was presented and online media reports for e-cigarette burns were queried with search terms "e-cigarette burns" and "electronic cigarette burns." The reports and injury patterns were tabulated. Analysis was then performed to create a novel classification system based on the distinct injury patterns seen in the study. Two patients were seen at our regional burn center after e-cigarette burns. One had an injury to his thigh and penis that required operative intervention after ignition of this device in his pocket. The second had a facial burn and corneal abrasions when the device exploded while he was inhaling vapor. The Internet search and case studies resulted in 26 cases for evaluation. The burn patterns were divided in direct injury from the device igniting and indirect injury when the device caused a house or car fire. A numerical classification was created: direct injury: type 1 (hand injury) 7 cases, type 2 (face injury) 8 cases, type 3 (waist/groin injury) 11 cases, and type 5a (inhalation injury from using device) 2 cases; indirect injury: type 4 (house fire injury) 7 cases and type 5b (inhalation injury from fire started by the device) 4 cases. Multiple e-cigarette injuries are occurring in the United States and distinct patterns of burns are emerging. The classification system developed in this article will aid in further study and future regulation of these dangerous devices.

Impact of advanced practice providers (nurse practitioners and physician assistants) on surgical residents' critical care experience.

BACKGROUND: Teaching hospitals often employ advanced practice providers (nurse practitioners and physician assistants or APPs) to counteract residents' work-hour restrictions. With increased utilization of APPs in labor-intense areas, such as intensive care units (ICUs), APPs may have an impact on resident education and experience. No studies have investigated the direct role an APP plays on the training experience of a surgical resident in the ICU. MATERIALS AND METHODS: An institutional review board-approved survey was emailed to residents in Accreditation Council for Graduate Medical Education-accredited general surgery programs. Surveys asked about demographics, residency and/or ICU characteristics, and the effects of APPs on patient care, workflow, and educational experience. Regression analysis determined predictors of resident perception. RESULTS: A total of 354 of 1178 residents responded to the survey (30%). Some residents felt that nurses calling APPs preferentially for patient-care issues interfered with education (17%) and residents' ability to follow patients (12%) and was associated with overall detrimental effects to ICU experience on regression (odds ratio, 3.7; confidence interval, 1.5-9.1). Most residents reported positive effects of APPs, such as reduced resident workload (79.8%), teaching protocols and/or guidelines (60.3%), enhanced patient care (60.3%), and enhanced communication (50.5%). When asked how APPs affected their overall ICU experience, 48.4% reported positive effects, 20.6% reported "no effect," and 31% reported detrimental effects. CONCLUSIONS: Only a minority of residents perceived that APPs detract from training, particularly those who felt excluded when nurses preferentially contact APPs with patient-care issues. APPs have the potential to enhance training and ICU experience, as reflected in many of the responses. Strategies to maintain direct nurse and resident communication might preserve residents' perception of the educational value of APPs.

Measuring satisfaction: factors that drive hospital consumer assessment of healthcare providers and systems survey responses in a trauma and acute care surgery population.

Hospital quality metrics now reflect patient satisfaction and are measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Understanding these metrics and drivers will be integral in providing quality care as this process evolves. This study identifies factors associated with patient satisfaction as determined by HCAHPS survey responses in trauma and acute care surgery patients. HCAHPS survey responses from acute care surgery and trauma patients at a single institution between 3/11 and 10/12 were analyzed. Logistic regression determined which responses to individual HCAHPS questions predicted highest hospital score (a rating of 9-10/10). Demographic and clinical variables were also analyzed as predictors of satisfaction. Subgroup analysis for trauma patients was performed. In 70.3 per cent of 182 total survey responses, a 9-10/10 score was given. The strongest predictors of highest hospital ranking were respect from doctors (odds ratio [OR] = 24.5, confidence interval [CI]: 5.44-110.4), doctors listening (OR: 9.33, CI: 3.7-23.5), nurses' listening (OR = 8.65, CI: 3.62-20.64), doctors' explanations (OR = 8.21, CI: 3.5-19.2), and attempts to control pain (OR = 7.71, CI: 3.22-18.46). Clinical factors and outcomes (complications, intensive care unit/hospital length of stay, mechanism of injury, and having an operation) were nonsignificant variables. For trauma patients, Injury Severity Score was inversely related to score (OR = 0.93, CI: 0.87-0.98). Insurance, education, and disposition were also tied to satisfaction, whereas age, gender, and ethnicity were nonsignificant. In conclusion, patient perception of interactions with the healthcare team was most strongly associated with satisfaction. Complications did not negatively influence satisfaction. Insurance status might potentially identify patients at risk of dissatisfaction. Listening to patients, treating them with respect, and explaining the care plan are integral to a positive perception of hospital stay.

Getting satisfaction: drivers of surgical Hospital Consumer Assessment of Health care Providers and Systems survey scores.

BACKGROUND: Hospital consumer assessment of health care providers and systems (HCAHPS) survey scores formally recognize that patients are central to health care, shifting quality metrics from the physician to patient perspective. This study describes clinical predictors of patient satisfaction in surgical patients. METHODS: Analysis of a single institution's Surgical Department HCAHPS responses was performed from March 2011-October 2012. The end points were top box satisfaction on two global domains. Multivariable regression was used to determine satisfaction predictors including HCAHPS domains, demographics, and clinical variables such as comorbidities, intensive care unit stay, emergency case, discharge day, floor transfers, complications, and ancillary procedures. RESULTS: In total, 978 surveys were evaluated representing admissions to Acute care and/or Trauma (n = 177, 18.1%), Thoracic (n = 169, 17.3%), Colorectal (n = 107, 10.9%), Transplant (n = 95, 9.7%), Vascular (n = 92, 9.4%), Oncology (n = 88, 9.0%), Plastic (n = 49, 5.0%), and Cardiac (n = 201, 20.6%) divisions. Overall, 658 patients (67.3%) had high satisfaction and 733 (74.9%) gave definite hospital recommendations. Hospital satisfaction was positively associated with an intensive care unit admission (odds ratio [OR] = 1.64, confidence interval [CI]: 1.20-2.23, P = 0.002) and satisfaction with provider and pain domains. Factors associated with decreased satisfaction were race (non-black minority compared with whites; OR = 0.41, CI: 0.21-0.83, P = 0.012), self-reported poor health (OR = 0.43, CI: 0.27-0.68, P < 0.001), ≥ 2 floor transfers (OR = 0.50, CI: 0.25-0.99, P = 0.046), and postoperative complications (OR = 0.67, CI: 0.55-0.82, P < 0.0001). In addition, weekend discharge (OR = 1.76, CI: 1.02-3.02, P = 0.041) was associated with hospital recommendation. CONCLUSIONS: Clinical course, particularly complications, impacts patient satisfaction. However, more important than what happens is how it happens, as evidenced by the much greater influence of surgeon and nurse-patient interactions. These results help inform future quality improvement and resource allocation.

Impact of a graduated driver's license law on crashes involving young drivers in New York State.

BACKGROUND: Motor vehicle crashes constitute the greatest risk of injury for young adults. Graduated driver licensing (GDL) laws have been used to reduce the number of injuries and deaths in the young driver population. The New York State GDL law increased supervision of young driver and limited both time-of-day driven and number of passengers. This review examines the impact of a GDL enacted in New York in September 2003. METHODS: A retrospective review of New York State administrative databases from 2001 to 2009 was performed. During this period, a state-wide GDL requirement was implemented. Database review included all reported crashes to the New York State Department of Motor Vehicles by cause and driver age as well as motor fuel tax receipts by the New York State Comptroller's Office. Motor fuel tax receipts and consumption information were used as a proxy for overall miles driven. RESULTS: Before 2003, drivers younger than 18 years were involved in 90 fatal crashes and 10,406 personal-injury (PI) crashes, constituting 4.49% and 3.38% of all fatal and PI crashes in New York State, respectively. By 2009, the number of fatal and PI crashes involving drivers who are younger than 18 years decreased to 44 (2.87%) and 5,246 (2.24%), respectively. Of note, the number of crashes experienced by the age group 18 years to 20 years during this period also declined, from 192 (9.59% of all fatal crashes) and 25,407 (8.24% of all PI crashes) to 135 (8.81%) and 18,114 (7.73%), respectively. Overall numbers of crashes reported remained relatively stable, between 549,000 in 2001 and 520,000 in 2009. Motor fuel use during this period also declined, but to a lesser degree ($552 million to $516 million or 6.6%). CONCLUSION: The use of a GDL law in New York State has shown a large decrease in the number of fatalities and PI crashes involving young drivers. The delay in full driver privileges from the GDL did not result in an increase in fatal or PI crashes in the next older age group.

Recombinant human thrombin: safety and immunogenicity in pediatric burn wound excision.

BACKGROUND: Previous studies of recombinant human thrombin (rThrombin) enrolled adult and adolescent patients. This phase 4, open-label, single-group study was conducted in pediatric patients undergoing synchronous burn wound excision and skin grafting to provide information regarding the safety and immunogenicity of rThrombin (primary and secondary endpoints) in this population. METHODS: Topical rThrombin was applied as a hemostatic aid during a surgical procedure (day 1). Adverse events and clinical laboratory abnormalities were recorded during the study. Immunogenicity samples were collected on days 1 and 29 (study end). Study results were summarized with descriptive statistics. RESULTS: Thirty patients enrolled and 28 completed the study. Mean age was 6.9 years (range, 0.9-17.8 years); 40.0% of patients were girls. Flame and scald were the most common burn types (33.3% each, n = 10/30). Mean graft size was 3.6% total body surface area. Procedural pain (50.0% patients), pruritus (43.3%), and anemia (30.0%) were the most commonly reported adverse events. All adverse events and clinical laboratory abnormalities were considered unrelated to treatment. No patients developed anti-rThrombin product antibodies at day 29. CONCLUSIONS: In pediatric patients undergoing burn wound excision and skin grafting, rThrombin was well tolerated and did not lead to the formation of anti-rThrombin product antibodies.

Burn resuscitation index: a simple method for calculating fluid resuscitation in the burn patient.

The Parkland formula is the standard for calculating the initial intravenous fluid rate for resuscutation after thermal injury. However, it is cumbersome when used by those with modest burn training. We propose an easier method to calculate fluid requirements that can be initiated by first-line providers. Burn size is estimated by using the Burn Size Score (BSS), which is then crossreferenced with the patient's weight on a preprinted Burn Resuscitation Index (BRI), based on the Parkland formula, to determine initial hourly fluid rate. Seventy-two residents and faculty in the Departments of Surgery and Emergency Medicine were surveyed. Participants were shown a diagram of a burn patient and asked to calculate the initial fluid rate using the Parkland formula from memory. The study was repeated with a different diagram, and the participants were asked to calculate the initial fluid rate using the BRI (a preprinted card with written instruction pertaining to its use). Statistical analysis was performed with the McNemar test. Using the Parkland formula, 33% of surgeons and 17% of emergency medicine physicians were able to calculate the initial fluid rate. Using the BRI, 56% of surgeons and 77% of emergency medicine physicians were able to calculate the fluid rate correctly (P < .01 and P < .001, respectively). Fifty-four percent of physicians surveyed believed that the BRI was easier to use. The accuracy of determining initial fluid rate was low using the Parkland formula and "rule of nines" from memory. Accuracy increased when the BRI was used. The BRI serves as a visual aid and provides some instruction, allowing the user to calculate fluid resuscitation with greater accuracy than with rote memorization of a formula. The BRI might be a useful tool for providers with minimal burn training. However, further investigation is warranted.

Development of a clothing iron safety device.

Contact burns from clothing irons are a common injury seen in children. These injuries occur when an unattended iron is within reach of toddlers in its upright position. In a previous study, the authors have shown that the surface of an iron takes 90 minutes to cool below the epidermal injury threshold of 49 degrees C. The authors have constructed an "iron shoe" to shield the iron surface from young hands during cooling. The device is intended to set the cooling iron in its down position providing additional protection. The device will insulate the iron surface to avoid the fire hazard when positioned in this manner. A silicone polymer was used to create an "iron shoe." This polymer is stable at temperatures up to 370 degrees C. The device included sidewalls to shield the edges from contact. Thermal analysis of the device was conducted using an inexpensive and expensive iron. Thermocouples were placed on the iron surface and below the iron shoe. The irons were heated to its maximum temperature, placed in the shoe and then unplugged. Temperature cooling curves were obtained from the thermocouples. The experiment was repeated by measuring the temperature difference between the iron edge and the shoe sidewalls. The surface of both expensive and inexpensive irons reached a maximum of 205 degrees C. The temperature below the iron shoe reached a maximum of 49 degrees C (inexpensive) and 60 degrees C (expensive). The iron edge temperature reached a maximum of 188 degrees C (inexpensive) and 154 degrees C (expensive). The shoe sidewall temperature achieved a maximum of 52 degrees C (inexpensive) and 49 degrees C (expensive). Both expensive and inexpensive irons reach temperatures over 200 degrees C. The silicone "iron shoe" effectively shielded the surface and edge of both irons and approached the epidermal injury threshold of 49 degrees C. The temperature beneath the expensive iron did exceed 49 degrees C, but because the intention of the device is to place the iron in the down position, the surface will be out of reach from children. This device prototype offers a solution to protect toddler's hands from contact with cooling irons. Further design modifications will be tested to reduce the cost of the device without impairing its effectiveness.