Bismuth/petroleum gauze plus high density polyethylene vs. bismuth/petroleum gauze: A comparison of donor site healing and patient comfort.

INTRODUCTION: Skin grafting continues to be a fundamental component of burn treatment and inherently, a donor site must be created and treated. Burn surgeons agree that specific dressings may have a significant affect on donor site healing, but we have no consensus as to which dressing provides maximum benefit. METHODS: Retrospective analysis of prospectively collected data from an observational, within-patient controlled assessment of a practice pattern intervention. The project compared donor sites treated with high-density polyethylene plus an overlying layer of bismuth/petroleum gauze to donor sites treated with bismuth/petroleum gauze alone. The primary endpoint was patient reported pain using a standard visual analog scale from 0 (no pain) to 10 (worst possible pain). A 2-point reduction in pain was considered clinically significant. Healing was defined as complete detachment of the dressings and> 95% wound re-epitheliazation. RESULTS: A total of 30 patients were observed and analyzed. Both dressings were associated with a mean pain rating of 6 out of 10 (STD= ± 2) and a median pain rating of 6 out of 10 (range = 0-10). Additionally, both dressings were associated with a mean healing time of 20 days (SEM=1.1). The subjective dressing preference showed that a majority of patients had no preference between the two modalities (n = 20). However, when an actual preference was stated (n = 10), bismuth/petroleum gauze alone was preferred by 9 out of 10 patients. CONCLUSION: Clinically and subjectively, we found no discernible differences between the 2 dressing regimens. Thus, bismuth/petroleum gauze alone is the more cost effective dressing choice. Our burn center continues to use bismuth/petroleum gauze alone as its standard of care for donor site dressings and will continue to try to define the optimal donor site dressing.

Results From an Evidenced-Based Curriculum Design With Innovative Simulators to Prepare Providers in Caring for Those With Burn Injuries.

Burn care and medical education have undergone dramatic changes. Trauma has over seven courses covering fundamentals, whereas burns has one. Our goal was to develop a course to meet the needs of healthcare professionals requiring more advanced burn management training. A survey was distributed to burn physicians, nurses, therapists, administrators, and survivors, to assess the perceived proficiency of those managing adult and pediatric patients. Procedure simulators were developed, and a course was designed and delivered. An after-course survey of participants captured how this course filled identified knowledge gaps. A total of 188 initial surveys were sent to individuals involved in burn care. A diverse pool of 109 individuals participated (58% response rate). Survey results by providers demonstrated the lowest self-rated proficiency scores at managing large pediatric burns and frostbite. Nonphysicians reported low proficiency in developing wound treatment algorithms, performing escharotomies, and aftercare/reintegration. Following rigorous curriculum development, the course was conducted, and after-course surveys noted students' improved understanding of managing burn injuries, ability to troubleshoot, confidence to manage patients, and their recommending the course to a peer. Providing quality care beyond the initial assessment and stabilization of a burn-injured patient requires additional skills and knowledge. Providers that are uncomfortable or challenged in providing this care may benefit from additional training. Initial data show that a course, such as this one, provides the education necessary to fill the most commonly reported gaps in knowledge and skills. Further work is being invested to develop disaster management skills, assessment components, and further determine course validity.

Updating the Burn Center Referral Criteria: Results From the 2018 eDelphi Consensus Study.

Existing burn center referral criteria were developed several years ago, and subsequent innovations in burn care have occurred. Coupled with frequent errors in the estimation of extent of burn injury and depth by referring providers, patients are both over and under-triaged when the existing criteria are used to support patient care decisions. In the absence of compelling clinical trial data on appropriate burn patient triage, we convened a multidisciplinary panel of experts to execute an iterative eDelphi consensus process to facilitate a revision. The eDelphi process panel consisted of n = 61 burn stakeholders and experts and progressed through four rounds before reaching consensus on key clinical domains. The major findings are that 1) burn center consultation is strongly recommended for all patients with deep partial-thickness or deeper burns ≥ 10% TBSA burned, for full-thickness burns ≥ 5% TBSA burned, for children and older adults with specific dressing and medical needs, and for special burn circumstances including electrical, chemical, and radiation injuries; 2) smaller burns are ideally followed in burn center outpatient settings as soon as possible after injury, preferably without delays of a week or more; 3) frostbite, Stevens-Johnson syndrome/TENS, and necrotizing soft-tissue infection patients benefit from burn center treatment; and 4) telemedicine and technological solutions are of likely benefit in achieving this standard. Unlike the original criteria, the revised consensus-based guidelines create a framework promoting communication so that triage and treatment are specifically tailored to individual patient characteristics, injury severity, geography, and the capabilities of referring institutions.

Return on investment of advanced practice medical degrees: NPs vs. PAs.

As the United States faces a predicted physician shortage over the next 2 decades, physician assistants (PAs) and NPs are expected to fill the void. At the same time, because education is expensive, student loan and tuition increases have many potential applicants assessing differences in reimbursement and wondering about their return on investment (ROI). An analysis compared PA and NP salaries by incorporating national salary data, federal income tax, and student loans for a comparative analysis of each career pathway. METHODS: Salaries were abstracted from the 2012 Bureau of Labor Statistics database. The net present value (NPV) of PA and NP salaries was calculated with a 5% discount rate. Principal and interest for student loans was calculated at a 6% interest fixed-rate loan over 30 years. NPVs were then compared with projected ROI at retirement age. Relative career values were also given to each career choice, based on a retirement age of 65 years, which translates to about 41 years of employment for both PAs and NPs. RESULTS: PAs' and NPs' educational loans both equalled $129,484 on total repayment. The median annual salary of a PA was $90,930 and $89,960 for an NP. PA data yielded a 5% NPV of $781,323 compared with $764,348 for NPs. Of note, the 5% NPV of a 4-year nursing degree is $728,436. CONCLUSION: PAs have a slightly higher ROI compared with NPs. These findings may change due to adjustments in nursing training models. Many PA programs allow matriculation immediately after obtaining a bachelor's degree. NP schools often require nursing experience before entering their program. Some schools are considering an accelerated NP program, allowing immediate matriculation after obtaining a bachelor's degree. Because many NP programs have become doctoral degrees, the increased duration of training, higher tuition, and fewer years worked before retirement lower the overall NP ROI. A similar reduction in ROI was considered marginal in PAs who attend residency programs-though these programs are not required for PAs to practice. Comparison of an RN with a 4-year degree to an NP shows little increase in ROI. If interest rates rise, it will become fiscally preferable to remain in a nursing position. Other intangible qualities exist and need further research (for example, weighing the financial aspects with lifestyle or professional satisfaction).

Advanced Burn Life Support for Day-to-Day Burn Injury Management and Disaster Preparedness: Stakeholder Experiences and Student Perceptions Following 56 Advanced Burn Life Support Courses.

Educational programs for clinicians managing patients with burn injuries represent a critical aspect of burn disaster preparedness. Managing a disaster, which includes a surge of burn-injured patients, remains one of the more challenging aspects of disaster medicine. During a 6-year period that included the development of a burn surge disaster program for one state, a critical gap was recognized as public presentations were conducted across the state. This gap revealed an acute and greater than anticipated need to include burn care education as an integral part of comprehensive burn surge disaster preparedness. Many hospital and prehospital providers expressed concern with managing even a single, burn-injured patient. While multiple programs were considered, Advanced Burn Life Support (ABLS), a national standardized educational program was selected to help address this need. The curriculum includes initial care for the burn-injured patient as well as an overview of the burn centers role in the disaster preparedness community. After 4 years and 56 classes conducted across the state, a survey was developed including a section that measured the perceptions of those who completed the ABLS educational program. The study specifically examines questions including whether clinicians perceived changes in their burn care knowledge, skills and abilities, and burn disaster preparedness following completion of the program? including whether clinicians.

Interactions between opioids and cocaine on locomotor activity in rats: influence of an opioid's relative efficacy at the mu receptor.

RATIONALE: Cocaine and mu opioid agonists increase central dopamine concentrations and produce robust interactions at both neurochemical and behavioral levels. Although the interactions between cocaine and high-efficacy mu opioids have been well characterized, the interactions between cocaine and lower efficacy opioids have not been as extensively examined. OBJECTIVE: The purpose of this study was to examine the interactions between cocaine and opioids possessing a range of relative efficacy at the mu receptor. METHODS: Male, Long-Evans rats were habituated to an open-field, locomotor activity chamber, and the effects of cocaine and various opioids were tested under a cumulative dosing procedure. In this procedure, a selected dose of an opioid was administered during the first component of a session, with increasing doses of cocaine administered during subsequent components. RESULTS: When administered alone, cocaine produced dose-dependent increases in locomotor activity that was stable across 5 weeks of behavioral testing. The high-efficacy mu opioid levorphanol, and the low-efficacy opioids buprenorphine, butorphanol, nalbuphine and (-)-pentazocine, dose-dependently enhanced the effects of cocaine at doses that did not alter locomotor activity when administered alone. In contrast, the opioid antagonist naloxone, and to a lesser extent, the kappa opioid spiradoline attenuated the effects of cocaine at doses that did not alter locomotor activity when administered alone. Across an extensive dose range, the low-efficacy opioid nalorphine failed to alter cocaine's locomotor-activating effects. CONCLUSIONS: These data suggest that low-efficacy opioids possessing significant mu-agonist activity (e.g. buprenorphine, butorphanol, nalbuphine, (-)-pentazocine) may potentiate the effects of cocaine in a manner similar to that typically observed with high-efficacy mu opioids.