Evaluating Real-World National and Regional Trends in Definitive Closure in U.S. Burn Care: A Survey of U.S. Burn Centers.

To better understand trends in burn treatment patterns related to definitive closure, this study sought to benchmark real-world survey data with national data contained within the National Burn Repository version 8.0 (NBR v8.0) across key burn center practice patterns, resource utilization, and clinical outcomes. A survey, administered to a representative sample of U.S. burn surgeons, collected information across several domains: burn center characteristics, patient characteristics including number of patients and burn size and depth, aggregate number of procedures, resource use such as autograft procedure time and dressing changes, and costs. Survey findings were aggregated by key outcomes (number of procedures, costs) nationally and regionally. Aggregated burn center data were also compared to the NBR to identify trends relative to current treatment patterns. Benchmarking survey results against the NBR v8.0 demonstrated shifts in burn center patient mix, with more severe cases being seen in the inpatient setting and less severe burns moving to the outpatient setting. An overall reduction in the number of autograft procedures was observed compared to NBR v8.0, and time efficiencies improved as the intervention time per TBSA decreases as TBSA increases. Both nationally and regionally, an increase in costs was observed. The results suggest resource use estimates from NBR v8.0 may be higher than current practices, thus highlighting the importance of improved and timely NBR reporting and further research on burn center standard of care practices. This study demonstrates significant variations in burn center characteristics, practice patterns, and resource utilization, thus increasing our understanding of burn center operations and behavior.

Representation Matters: An Assessment of Diversity in Current Major Textbooks on Burn Care.

Ethnic and gender disparities in healthcare have been well described. Increasing attention is paid to representative diversity in the images and educational resources used during medical training. Nearly 40% of the population of the United States identifies as a person of color, and patients of color reflect 41% of the total burn population seen in the United States. Additionally, national data on providers suggest about 5% of the Burn Team should be people of color. A better understanding of the diversity represented by burn-related medical literature could affect the management of patients with diverse backgrounds, as well as recruitment of black, indigenous, and people of color (BIPOC) into this field. The goal of this study is to investigate the representation of diverse skin tones in several leading medical textbooks of burn care. All photographs that contained people were evaluated for the number of people present and the depicted role of the person present. Diversity count was assessed in a binary fashion-was the individual represented a BIPOC? About 2579 total individuals were identified. BIPOC was represented in 363 total images (14%). There were 6 providers of color identified out of a total of 161 (3.7%); 30 providers were women (19%), of whom only 1 was a female provider of color. BIPOC patients and providers are underrepresented in the leading textbooks of burn care. Proper representation must be included in modern educational materials to better prepare providers for a diverse population of burn-injured patients and ensure effective and thoughtful care.

Institutional Experience Using a Treatment Algorithm for Electrical Injury.

Electrical injury has low incidence but is associated with high morbidity and mortality. Variability in diagnosis and management among clinicians can lead to unnecessary testing. This study examines the utility of an electrical injury treatment algorithm by comparing the incidence of testing done on a cohort of patients before and after implementation. Demographics, injury characteristics, and treatment information were collected for patients arriving to a regional burn center with the diagnosis of electrical injury from January 2013 to September 2018. Results were compared for patients admitted before and after the implementation of an electrical injury treatment algorithm in July 2015. There were 56 patients in the pre-algorithm cohort and 38 in the post-algorithm cohort who were of similar demographics. The proportion of creatine kinase (82% vs 47%, P < .0006), troponin (79% vs 34%, P < .0001), and urinary myoglobin (80% vs 45%, P < .0007) testing in the pre-algorithm cohort was significantly higher compared to post-algorithm cohort. There were more days of telemetry monitoring (median [IQR], 1 [1-5] vs 1 [1-1] days, P = .009) and greater ICU length of stays (4 [1-5] vs 1 [1-1] days, P = .009), prior to algorithm implementation. There were no significant differences in total hospital lengths of stay, incidence of ICU admissions, in-hospital mortality, or 30-day readmissions. This study demonstrates an electrical injury evaluation and treatment algorithm suggests a mode of triage to cardiac monitoring and hospital admission where necessary. Use of this algorithm allowed for reduction in testing and health care costs without increasing mortality or readmission rates.

An Assessment of Research Priorities to Dampen the Pendulum Swing of Burn Resuscitation.

On June 17 to 18, 2019, the American Burn Association, in conjunction with Underwriters Laboratories, convened a group of experts on burn resuscitation in Washington, DC. The goal of the meeting was to identify and discuss novel research and strategies to optimize the process of burn resuscitation. Patients who sustain a large thermal injury (involving >20% of the total body surface area [TBSA]) face a sequence of challenges, beginning with burn shock. Over the last century, research has helped elucidate much of the underlying pathophysiology of burn shock, which places multiple organ systems at risk of damage or dysfunction. These studies advanced the understanding of the need for fluids for resuscitation. The resultant practice of judicious and timely infusion of crystalloids has improved mortality after major thermal injury. However, much remains unclear about how to further improve and customize resuscitation practice to limit the morbidities associated with edema and volume overload. Herein, we review the history and pathophysiology of shock following thermal injury, and propose some of the priorities for resuscitation research. Recommendations include: studying the utility of alternative endpoints to resuscitation, reexamining plasma as a primary or adjunctive resuscitation fluid, and applying information about inflammation and endotheliopathy to target the underlying causes of burn shock. Undoubtedly, these future research efforts will require a concerted effort from the burn and research communities.

Cross-Sectional Assessment of Burn Center and Nonburn Center Patient Care: A Multi-Database Comparison.

The practice of burn care is complex and continues to be a rapidly evolving field. To assess how differences in management affect hospital stay characteristics and outcomes, the authors sought to compare outcomes data from two sources, such as burn center and nonburn center data. The National Burn Repository (NBR, version 8) and the 2014 Nationwide Readmission Database (NRD) were compared based on ICD-9 948-series burn-related diagnosis codes, generating a total of 83,068 and 14,131 burn patients from the NBR and NRD, respectively. Patients were stratified by burn size and compared based on demographic factors and hospital stay characteristics. t-Test and chi-squared statistics were performed with SAS, version 9.4. Burn patient populations from the NBR and NRD databases, when stratified by patient demographic factors, were found to have similar sex distributions, 68% and 64% male, respectively. The average age was significantly higher in the NRD data at 39.5 ± 23.6 compared with 30.9 ± 22.3 years. Hospital stay characteristics, including length of stay and mortality, were not found to differ significantly. Differences were identified in the number of trips to the OR, which was significantly greater in the NBR population as well as the total cost of care, which was significantly less in the NBR population at $92k compared with $125k. This study has shown through the interpretation of multiple databases that not only do demographics differ between burn and nonburn center populations, but also do management strategies, particularly in operative intervention and cost.

Pro-Con Perspectives on Ethics in Surgical Research: Update from the 39th Annual Surgical Infection Society Meeting.

Background: Surgical research is potentially invasive, high-risk, and costly. Research that advances medical dogma must justify both its ends and its means. Although ethical questions do not always have simple answers, it is critically important for the clinician, researcher, and patient to approach these dilemmas and surgical research in a thoughtful, conscientious manner. Methods: We present four ethical issues in surgical research and discuss the opposing viewpoints. These topics were presented and discussed at the 39th Annual Meeting of the Surgical Infection Society as pro-con debates. The presenters of each opinion developed a succinct summary of their respective reviews for this publication. Results: The key subjects for these pro-con debates were: (1) Should patients be enrolled for time-sensitive surgical infection research using an opt-out or an opt-in strategy? (2) Should patients who are being enrolled in a randomized controlled trial (RCT) comparing surgery with a non-operative intervention pay the costs of their treatment arm? (3) Should the scientific community embrace open access journals as the future of scientific publishing? (4) Should the majority of funding go to clinical or basic science research? Important points were illustrated in each of the pro-con presentations and illustrated the difficulties that are facing the performance and payment of infection research in the future. Conclusions: Surgical research is ethically complex, with conflicting demands between individual patients, society, and healthcare economics. At present, there are no clear answers to these and the many other ethical issues facing research in the future. Answers will only come from continued robust dialogue among all stakeholders in surgical research.

Utilizing Plasma Composition Data to Help Determine Procoagulant Dynamics in Patients with Thermal Injury: A Computational Assessment.

INTRODUCTION: The development of methods that generate individualized assessments of the procoagulant potential of burn patients could improve their treatment. Beyond its role as an essential intermediate in the formation of thrombin, factor (F)Xa has systemic effects as an agonist to inflammatory processes. In this study, we use a computational model to study the FXa dynamics underlying tissue factor-initiated thrombin generation in a small cohort of burn patients. MATERIALS AND METHODS: Plasma samples were collected upon admission (Hour 0) from nine subjects (five non-survivors) with major burn injuries and then at 48 hours. Coagulation factor concentrations (II, V, VII, VIII, IX, X, TFPI, antithrombin (AT), protein C (PC)) were measured and used in a computational model to generate time course profiles for thrombin (IIa), FXa, extrinsic tenase, intrinsic tenase and prothrombinase complexes upon a 5 pM tissue factor stimulus in the presence of 1 nM thrombomodulin. Parameters were extracted from the thrombin and FXa profiles (including max rate (MaxRIIa and MaxRFXa) and peak level (MaxLIIa and MaxLFXa)). Procoagulant potential was also evaluated by determining the concentration of the complexes at select times. Parameter values were compared between survivors and non-survivors in the burn cohort and between the burn cohort and a simulation based on the mean physiological (100%) concentration for all factor levels. RESULTS: Burn patients differed at Hour 0 (p < 0.05) from 100% mean physiological levels for all coagulation factor levels except FV and FVII. The concentration of FX, FII, TFPI, AT and PC was lower; FIX and FVIII were increased. The composition differences resulted in all nine burn patients at Hour 0 displaying a procoagulant phenotype relative to 100% mean physiological simulation (MaxLIIa (306 ± 90 nM vs. 52 nM), MaxRIIa (2.9 ± 1.1 nM/s vs. 0.3 nM/s), respectively p < 0.001); MaxRFXa and MaxLFXa were also an order of magnitude greater than 100% mean physiological simulation (p < 0.001). When grouped by survival status and compared at the time of admission, non-survivors had lower PC levels (56 ± 18% vs. 82 ± 9%, p < 0.05), and faster MaxRFXa (29 ± 6 pM/s vs. 18 ± 6 pM/s, p < 0.05) than those that survived; similar trends were observed for all other procoagulant parameters. At 48 hours when comparing non-survivors to survivors, TFPI levels were higher (108 ± 18% vs. 59 ± 18%, p < 0.05), and MaxRIIa (1.5 ± 1.4 nM/s vs. 3.6 ± 0.7 nM/s, p < 0.05) and MaxRFXa (13 ± 12 pM/s vs. 35 ± 4 pM/s, p < 0.05) were lower; similar trends were observed with all other procoagulant parameters. Overall, between admission and 48 hours, procoagulant potential, as represented by MaxR and MaxL parameters for thrombin and FXa, in non-survivors decreased while in survivors they increased (p < 0.05). In patients that survived, there was a positive correlation between FX levels and MaxLFXa (r = 0.96) and reversed in mortality (r= -0.91). CONCLUSIONS: Thrombin and FXa generation are increased in burn patients at admission compared to mean physiological simulations. Over the first 48 hours, burn survivors became more procoagulant while non-survivors became less procoagulant. Differences between survivors and non-survivors appear to be present in the underlying dynamics that contribute to FXa dynamics. Understanding how the individual specific balance of procoagulant and anticoagulant proteins contributes to thrombin and FXa generation could ultimately guide therapy and potentially reduce burn injury-related morbidity and mortality.

Assessment of Coagulation Homeostasis in Blunt, Penetrating, and Thermal Trauma: Guidance for a Multicenter Systems Biology Approach.

INTRODUCTION: Provisioning care for traumatically injured patients makes conducting research very proximal to injury difficult. These studies also inherently have regulatory barriers to overcome. Here we outline a protocol for acute-phase enrollment of traumatically injured patients into a prospective observational clinical trial with precise and comprehensive sample acquisition in support of a systems biology approach to a research study. METHODS: Experts in trauma, burn, blood coagulation, computational biology, and integrative systems biology developed a prospective study that would capture the natural history of coagulation pathology after traumatic injury. Blood was sampled at admission and serial time points throughout hospitalization. Concurrently, demographic and outcomes data were recorded and on-site point-of-care testing was implemented. Protocols were harmonized across sites and sampling protocols validated through demonstration of feasibility and sample quality assurance testing. A novel data integration platform was developed to store, visualize, and enable large-scale analysis of empirical and clinical data. Regulatory considerations were also addressed in protocol development. RESULTS: A comprehensive Manual of Operations (MOO) was developed and implemented at 3 clinical sites. After regulatory approval, the MOO was followed to collect 5,348 longitudinal samples from 1,547 patients. All samples were collected, processed, and stored per the MOO. Assay results and clinical data were entered into the novel data management platform for analyses. CONCLUSION: We used an iterative, interdisciplinary process to develop a systematic and robust protocol for comprehensive assessment of coagulation in traumatically injured patients. This MOO can be a template for future studies in the acute setting.

Contemplating a Career in Burn Surgery: Data From the 2016 Burn Physician Survey.

There is a paucity of information in the peer-reviewed literature characterizing the current burn surgeon workforce and compensation potential, and, in a parallel topic, training opportunities and recruitment methods. What does exist documents minimal exposure to the field and surgeon shortages. A comprehensive survey was created to address 1) the demographics of current burn surgeons in practice, and 2) the structure of burn centers training models. Finally, three questions were asked regarding job satisfaction. With a response rate of 23%, demographics reflect representative involvement across the age spectrum. The majority of respondents (73.9%) had training in general surgery, with subsequent postgraduate training primarily in surgical critical care or burn fellowships. Two-thirds of respondents have active practices, cover multiple specialties, and take multispecialty call throughout the month. A variety of models are used to calculate compensation. The vast majority of burn centers train residents: general surgery residents (89%), plastic surgery residents (63%), and emergency medicine residents (32%), most of whom are in their first 3 years of training. The majority of respondents would become a burn surgeon again if they had to do it over and would recommend it to young surgeons as a career. A representative sample of burn surgeons from across North America sustains practices in similar ways. Access to the next generation of surgeons is at an early period in training (PGY1-3) which may prove valuable as surgical education evolves. Overall, burn surgeons express good job satisfaction, a significant point of interest as attention turns towards succession planning.

Defining Adequate Quality and Safety Metrics for Burn Care.

While current evidence-based practices might be applicable to caring for patients with routine diseases and common injury patterns, their application to burn care is less clear. Quality metrics created for large patient populations have failed to account for diseases that are not included in landmark research. Tasked to provide not only medically appropriate but also high-quality and cost-effective care for patients, burn clinicians must find a balance between patient-specific quality metrics and external quality metrics.

A new approach for optical assessment of directional anisotropy in turbid media.

A study of polarized light transport in scattering media exhibiting directional anisotropy or linear birefringence is presented in this paper. Novel theoretical and experimental methodologies for the quantification of birefringent alignment based on out-of-plane polarized light transport are presented here. A polarized Monte Carlo model and a polarimetric imaging system were devised to predict and measure the impact of birefringence on an impinging linearly polarized light beam. Ex-vivo experiments conducted on bovine tendon, a biological sample consisting of highly packed type I collagen fibers with birefringent property, showed good agreement with the analytical results.

Noninvasive imaging technologies for cutaneous wound assessment: A review.

The ability to phenotype wounds for the purposes of assessing severity, healing potential and treatment is an important function of evidence-based medicine. A variety of optical technologies are currently in development for noninvasive wound assessment. To varying extents, these optical technologies have the potential to supplement traditional clinical wound evaluation and research, by providing detailed information regarding skin components imperceptible to visual inspection. These assessments are achieved through quantitative optical analysis of tissue characteristics including blood flow, collagen remodeling, hemoglobin content, inflammation, temperature, vascular structure, and water content. Technologies that have, to this date, been applied to wound assessment include: near infrared imaging, thermal imaging, optical coherence tomography, orthogonal polarization spectral imaging, fluorescence imaging, laser Doppler imaging, microscopy, spatial frequency domain imaging, photoacoustic detection, and spectral/hyperspectral imaging. We present a review of the technologies in use or development for these purposes with three aims: (1) providing basic explanations of imaging technology concepts, (2) reviewing the wound imaging literature, and (3) providing insight into areas for further application and exploration. Noninvasive imaging is a promising advancement in wound assessment and all technologies require further validation.

Examination of the Early Diagnostic Applicability of Active Dynamic Thermography for Burn Wound Depth Assessment and Concept Analysis.

Despite advances in perfusion imaging, burn wound imaging technology continues to lag behind that of other fields. Quantification of blood flow is able to predict time for healing, but clear assessment of burn depth is still questionable. Active dynamic thermography (ADT) is a noncontact imaging modality capable of distinguishing tissue of different thermal conductivities. Utilizing the abnormal heat transfer properties of the burn zones, we examined whether ADT was useful in the determination of burn depth in a model of early burn wound evaluation. Duroc pigs (castrated male; n = 3) were anesthetized, and two burns were created with an aluminum billet at 3 and 12 seconds. These contact times resulted in superficial partial and deep partial thickness burn wounds, respectively. ADT and laser Doppler imaging (LDI) imaging were performed every 30 minutes postburn for a total of five imaging sessions ending 150 minutes postburn. For ADT, imaging excitation was performed for 42-120 seconds with dual quartz-infrared lamps, and subsequent infrared image capture was performed for 300 seconds. MATLAB-assisted image analysis was performed to determine burn zone region of interest thermal relaxation and characteristic patterns. LDI was performed with a moorLDI system, and biopsies were captured for histology following the 150-minute imaging session. Both ADT and LDI imaging modalities are able to detect different physical properties at 30, 60, 90 120, and 150 minutes postburn with statistical significance (P < 0.05). Resultant ADT cooling curves characterize greater differences with greater stimulation and a potentially more identifiable differential cooling characteristic. Histological analysis confirmed burn depth. This preliminary work confirms that ADT can measure burn depth and is deserving of further research either as a stand-alone imaging technology or in combination with a device to assess perfusion.

A multimodal assessment of melanin and melanocyte activity in abnormally pigmented hypertrophic scar.

Using a validated swine model of human scar formation, hyperpigmented and hypopigmented scar samples were examined for their histological and optical properties to help elucidate the mechanisms and characteristics of dyspigmentation. Full-thickness wounds were created on the flanks of red Duroc pigs and allowed to heal. Biopsies from areas of hyperpigmentation, hypopigmentation, and uninjured tissue were fixed and embedded for histological examination using Azure B and primary antibodies to S100B, HMB45, and α-melanocyte-stimulating hormone (α-MSH). Spatial frequency domain imaging (SFDI) was then used to examine the optical properties of scars. Hyperpigmentation was first noticeable in healing wounds around weeks 2 to 3, gradually becoming darker. There was no significant difference in S100B staining for the presence of melanocytes between hyperpigmented and hypopigmented scar samples. Azure B staining of melanin was significantly greater in histological sections from hyperpigmented areas than in sections from both uninjured skin and hypopigmented scar (P < .0001). There was significantly greater staining for α-MSH in hyperpigmented samples compared with hypopigmented samples (P = .0121), and HMB45 staining was positive for melanocytes in hyperpigmented scar. SFDI at a wavelength of 632 nm resulted in an absorption coefficient map correlating with visibly hyperpigmented areas of scars. In a red Duroc model of hypertrophic scar formation, melanocyte number is similar in hyperpigmented and hypopigmented tissues. Hyperpigmented tissues, however, show a greater amount of melanin and α-MSH, along with immunohistochemical evidence of stimulated melanocytes. These observations encourage further investigation of melanocyte stimulation and the inflammatory environment within a wound that may influence melanocyte activity. Additionally, SFDI can be used to identify areas of melanin content in mature, pigmented scars, which may lead to its usefulness in wounds at earlier time points before markedly apparent pigmentation abnormalities.

A polarized multispectral imaging system for quantitative assessment of hypertrophic scars.

Hypertrophic scars (HTS) are a pathologic reaction of the skin and soft tissue to burn or other traumatic injury. Scar tissue can cause patients serious functional and cosmetic issues. Scar management strategies, specifically scar assessment techniques, are vital to improve clinical outcome. To date, no entirely objective method for scar assessment has been embraced by the medical community. In this study, we introduce for the first time, a novel polarized multispectral imaging system combining out-of-plane Stokes polarimetry and Spatial Frequency Domain Imaging (SFDI). This imaging system enables us to assess the pathophysiology (hemoglobin, blood oxygenation, water, and melanin) and structural features (cellularity and roughness) of HTS. To apply the proposed technique in an in vivo experiment, dermal wounds were created in a porcine model and allowed to form into scars. The developed scars were then measured at various time points using the imaging system. Results showed a good agreement with clinical Vancouver Scar Scale assessment and histological examinations.

Donor site healing dynamics: molecular, histological, and noninvasive imaging assessment in a porcine model.

Understanding the physiology of donor site healing will lead to advances in how these wounds are treated and may ultimately allow faster healing, more frequent autografting, and more effective care of the burn-injured patient. Unfortunately, a paucity of data exists regarding perfusion metrics over the course of donor site healing. Furthermore, there are no studies that interrelate indices of perfusion with the molecular and cellular processes of donor site healing. Male Duroc pigs were anesthetized and donor site wounds were created using a Zimmer dermatome at a depth of 0.060 inch (1.52 mm). Digital photographs, laser Doppler images, and punch biopsies were obtained before and after excision and on days 2, 4, 7, 9, 11, 14, and 16 until wounds were healed. RNA isolation was performed and quantitative polymerase chain reaction was used to examine differential gene expression over the time course. Formalin-fixed biopsies were embedded in paraffin, sectioned, stained, and examined. Wound surfaces were 83% re-epithelialized by day 16. Perfusion peaked on day 2 then declined, but it remained significantly elevated compared to before excision (P < .05). From day 9 onward, mean perfusion units were not significantly different from baseline (P < .05). Twenty-two representative genes were selected for examination. RNA expression of collagen, tenascin-cytoactin, inflammatory cytokines, remodeling enzymes, growth factors, and Wnt was increased. Inflammatory cells and cytokines were demonstrated histologically. Nuclei per high powered field peaked at day 7 and neodermal thickness increased daily to day 14. A novel porcine model for donor site wound healing that interrelates re-epithelilaizationand perfusion with molecular and cellular indices has been demonstrated.

Critical review of burn depth assessment techniques: part II. Review of laser doppler technology.

The judgment of which wounds are expected to heal within 21 days is one of the most difficult and important tasks of the burn surgeon. The quoted accuracy of 64 to 76% by senior burn surgeons underscores the importance of an adjunct technology to help make this determination. A plethora of techniques have been developed in the last 70 years. Laser Doppler imaging (LDI) is one of the most recent and widely studied of these techniques. The technology provides an estimate of perfusion through the burn wound, the assumption being that a lower perfusion correlates with a deeper wound and, therefore, a longer time to heal. Although some reports suggest accuracy between 96 and 100% and that it does this 2 days ahead of clinical judgment, others have questioned its applicability to clinical practice. This article, the second of a two-part series, has two objectives: 1) a review of the Doppler principle and how the LDI uses it to estimate perfusion; and 2) a critical assessment of the burn literature on the LDI. Part I provides a historical perspective of the different technologies used through the last 70 years to assist in the determination of burn depth. Laser Doppler has brought technology closer to provide a reliable adjuvant to the clinical prediction of healing, yet, caution is warranted. A clear understanding of the limitations of LDI is needed to put the current research in perspective to find the right clinical application for LDI.

Critical review of burn depth assessment techniques: Part I. Historical review.

The assessment of burn depth, and as such, the estimation of whether a burn wound is expected to heal on its own within 21 days, is one of the most important roles of the burn surgeon. A false-positive assessment and the patient faces needless surgery, a false-negative one and the patient faces increased length of stay, risks contracture, and hypertrophic scar formation. Although many clinical signs can aid in this determination, accurate assessment of burn depth is possible only 64 to 76% of the time, even for experienced burn surgeons. Through the years, a variety of tools have become available, all attempting to improve clinical accuracy. Part 1 of this two-part article reviews the literature supporting the different adjuvants to clinical decision making is, providing a historical perspective that serves as a framework for part 2, a critical assessment of laser Doppler imaging.