Administration and effects of beta blockers and oxandrolone in severely burned adults: a post hoc analysis of the RE-ENERGIZE trial.

Background: Prospective randomized trials in severely burned children have shown the positive effects of oxandrolone (OX), beta blockers (BB) and a combination of the two (BBOX) on hypermetabolism, catabolism and hyperinflammation short- and long-term post-burn. Although data on severely burned adults are lacking in comparison, BB, OX and BBOX appear to be commonly employed in this patient population. In this study, we perform a secondary analysis of an international prospective randomized trial dataset to provide descriptive evidence regarding the current utilization patterns and potential treatment effects of OX, BB and BBOX. Methods: The RE-ENERGIZE (RandomizEd Trial of ENtERal Glutamine to minimIZE Thermal Injury, NCT00985205) trial included 1200 adult patients with severe burns. We stratified patients according to their receipt of OX, BB, BBOX or none of these drugs (None) during acute hospitalization. Descriptive statistics describe the details of drug therapy and unadjusted analyses identify predisposing factors for drug use per group. Association between OX, BB and BBOX and clinical outcomes such as time to discharge alive and 6-month mortality were modeled using adjusted multivariable Cox regressions. Results: More than half of all patients in the trial received either OX (n = 138), BB (n = 293) or BBOX (n = 282), as opposed to None (n = 487, 40.6%). Per study site and geographical region, use of OX, BB and BBOX was highly variable. Predisposing factors for the use of OX, BB and BBOX included larger total body surface area (TBSA) burned, higher acute physiology and chronic health evaluation (APACHE) II scores on admission and younger patient age. After adjustment for multiple covariates, the use of OX was associated with a longer time to discharge alive [hazard ratio (HR) 0.62, confidence interval (CI) (0.47-0.82) per 100% increase, p = 0.001]. A higher proportion of days on BB was associated with lower in-hospital-mortality (HR: 0.5, CI 0.28-0.87, p = 0.015) and 6-month mortality (HR: 0.44, CI 0.24-0.82, p = 0.01). Conclusions: The use of OX, BB and BBOX is common within the adult burn patient population, with its use varying considerably across sites worldwide. Our findings found mixed associations between outcomes and the use of BB and OX in adult burn patients, with lower acute and 6-month-mortality with BB and longer times to discharge with OX. Further research into these pharmacological modulators of the pathophysiological response to severe burn injury is indicated.

Utility of a pediatric psychosocial screener in an outpatient burn clinic.

Psychosocial concerns are common among youth who sustained a burn injury. Detecting psychosocial distress early is essential to ensure appropriate treatment and referrals. Thus far, research has focused largely on long-term outcomes of pediatric burn survivors. The current quality improvement initiative details the implementation and outcomes of brief, pragmatic screening to assess psychosocial concerns among pediatric burn survivors in an outpatient setting. A primary caregiver completed an age-appropriate psychosocial screener for youth ages 4-10 years (n=69), while patients aged 11-17 years (n=72) completed a self-report screener. Total scores were used to categorize patients as acute risk (i.e., emotional concerns requiring immediate attention), moderate-risk (i.e., elevated symptoms, but no immediate safety concerns), or low-risk (i.e., endorsing few to no symptoms). Acute risk patients were evaluated by medical staff to determine the need for immediate psychiatry intervention or social services referrals. Moderate-risk patients met with the on-site psychology team during their clinic visit or were contacted by telephone within one week. Patients in the low-risk category warranted no additional follow-up post-screening. Most patients scored in the low-risk category (n=120; 85%), while 11% (n=16) and 4% (n=5) endorsed symptoms consistent with moderate and acute risk, respectively. Results demonstrate the utility of implementing pediatric psychosocial screening in an outpatient burn clinic, the importance of detecting psychosocial concerns in this context, and usage of referrals to address concerns. Findings also shed light on key caveats of psychosocial screening, barriers to accessing psychosocial support, and the potential benefits of embedded psychological support during medical visits.

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

OBJECTIVES: ABRUPT was a prospective, noninterventional, observational study of resuscitation practices at 21 burn centers. The primary goal was to examine burn resuscitation with albumin or crystalloids alone, to design a future prospective randomized trial. SUMMARY BACKGROUND DATA: No modern prospective study has determined whether to use colloids or crystalloids for acute burn resuscitation. METHODS: Patients ≥18 years with burns ≥ 20% total body surface area (TBSA) had hourly documentation of resuscitation parameters for 48 hours. Patients received either crystalloids alone or had albumin supplemented to crystalloid based on center protocols. RESULTS: Of 379 enrollees, two-thirds (253) were resuscitated with albumin and one-third (126) were resuscitated with crystalloid alone. Albumin patients received more total fluid than Crystalloid patients (5.2 ± 2.3 vs 3.7 ± 1.7 mL/kg/% TBSA burn/24 hours), but patients in the Albumin Group were older, had larger burns, higher admission Sequential Organ Failure Assessment (SOFA) scores, and more inhalation injury. Albumin lowered the in-to-out (I/O) ratio and was started ≤12 hours in patients with the highest initial fluid requirements, given >12 hours with intermediate requirements, and avoided in patients who responded to crystalloid alone. CONCLUSIONS: Albumin use is associated with older age, larger and deeper burns, and more severe organ dysfunction at presentation. Albumin supplementation is started when initial crystalloid rates are above expected targets and improves the I/O ratio. The fluid received in the first 24 hours was at or above the Parkland Formula estimate.

Descriptive Analysis of Current Burn Care for Plain Communities in Ohio and Pennsylvania: A Qualitative Study of Strengths and Needs in a Hospital-Community Partnership.

Plain communities present with a higher risk of sustaining burn injuries. Yet, little is known about the hospital-community partnerships with Plain caretakers to facilitate culturally competent burn care. The current study provides a qualitative analysis of Plain caretakers' perspectives on an existing hospital-community partnership for facilitating culturally sensitive burn care and their perspectives on the ongoing physical, structural, and behavioral health needs of this population. Twelve Plain community caregivers who serve on a burn wound treatment team or an oil therapy team within their community took part in a focus group interview. Caretakers identified as White, were majority male (83%), and resided in Plain communities. Retrospective thematic analysis was used to analyze the data. Five major themes (ie, informational needs, strengths of Plain community burn care, behavioral health concerns, behavioral health resources, and preferred teaching methods) evolved. Results revealed that Plain caregivers displayed an openness to learning about recommended burn care from the medical providers. Caretakers also cited their traditional (homeopathic) burn care procedures as perceived strengths, while simultaneously maintaining that their relationship with the hospital is a valuable part of life-saving burn care. Regarding their behavioral health needs, caretakers highlighted difficulties in helping their children cope with burn injuries and pain during rehabilitation and treatment. Other topics discussed included social support and cultural factors that impact the delivery of burn care to Plain communities from non-Plain providers. These results provide important considerations that other burn centers may consider when establishing similar partnerships to deliver of culturally competent medicine for Plain burn survivors.

Coping in Pediatric Burn Survivors and Its Relation to Social Functioning and Self-Concept.

Pediatric burn survivors experience increased risk for bullying, stigmatization, body image concerns, and problematic social functioning. Although coping behaviors are associated with engagement in social supports and positive self-concept in multiple pediatric illness populations, their relation has not been examined in pediatric burns. This study examined coping in relation to social functioning and self-concept in 51 pediatric burn survivors aged 7-17years (M=12.54; SD=2.65). Survivors and their caregivers completed the Child Coping Strategies Checklist (CCSC; youth report); the Burn Injury Social Questionnaire (BISQ; parent and youth report); and the Piers-Harris Children's Self-Concept Scale-2 (PH-2; youth report). Associations between coping, social functioning, self-concept, demographic features, and burn injury characteristics were examined via bivariate correlations. Hierarchical linear regressions examined whether coping strategies predicted social functioning and youth self-concept beyond burn injury and demographic variables. Social functioning concerns were positively correlated with total body surface area (TBSA; r=0.63 and 0.40, respectively). TBSA was the only significant predictor of parent-reported social concerns (ß=0.65, p<0.001). Greater distraction coping predicted fewer youth-reported social concerns (ß=-0.39, p=0.01). Greater active coping (B=0.67, p=0.002) and lower avoidance coping (B=-0.36, p=0.03) predicted better youth-reported self-concept. This study advances our understanding of coping as potentially protective for psychosocial adjustment. Clinicians working with child burn survivors should incorporate active coping interventions into treatment. Further research including larger and more diverse samples is needed to understand the role of coping approaches on psychological adjustment during burn healing.

Neodermis Formation in Full Thickness Wounds Using an Esterified Hyaluronic Acid Matrix.

The role of the dermis is essential for the proper orchestration of all phases of the normal wound healing process. Wounds with seriously damaged or even absent dermis consistently show seriously impaired wound healing and/or long-term complications such as hypertrophic scarring. Replacing a damaged dermis requires a dermal matrix that is compatible with, or even stimulates, the process of wound healing. Hyaluronic acid (HA), in an esterified form, is among the many matrices that are available. HA has been used in a number of indications, such as ulcers (ie, diabetic foot ulcers and venous leg ulcers), trauma, including burns, and for the repair of contractures and hypertrophic scars. The shorter healing time and the decrease of recurring hypertrophy demonstrate the efficiency of HA-derived matrices. Biopsies, taken up to 12 months post-reconstruction show a neodermis that histologically is largely comparable to normal skin, which probably is a function of HA playing such a pivotal role in normal, unwounded skin, as well as in the process of healing.

The Role of Youth Coping Strategies and Caregiver Psychopathology in Predicting Posttraumatic Stress Symptoms in Pediatric Burn Survivors.

Caregiver psychosocial functioning is repeatedly linked with postburn adjustment in pediatric burn survivors. However, few studies have examined youth characteristics as predictors, such as coping strategies. Furthermore, research has not explored how caregiver psychopathology and youth coping strategies interact to predict youth postburn adjustment. The aim of this study was to examine how youth coping strategies and caregiver anxiety and depression predict youth posttraumatic stress symptoms (PTSS). Forty-six youth between 7 and 17 years old (M = 12.5, SD = 2.65) and their caregivers were recruited from two U.S. burn centers. Youth and parents completed questionnaires that assessed demographics, caregiver anxiety, and depression, youth self-reports of coping strategies, and youth PTSS. Burn injury data (e.g. TBSA, time since injury) was obtained from medical record reviews. Hierarchical regressions were conducted with caregiver psychopathology (depression, anxiety), youth coping strategies (active, avoidant, distraction, social support), and the interaction between caregiver psychopathology and youth coping strategies as predictors and youth PTSS as the outcome variable. Higher levels of caregiver anxiety (ßs = .36 to .42) and avoidance coping (ßs = .38 to .43) were associated with more PTSS. Caregiver anxiety and depression moderated the association between youth use of distraction coping and youth PTSS. These findings reinforce the importance of assessing psychosocial functioning in pediatric burn survivors and their caregivers, and providing interventions to promote better psychosocial outcomes. Coping strategies may help reduce PTSS and buffer against the harmful influence of caregiver psychopathology. Future research may wish to pilot interventions that promote healthy coping.

Predicting Adolescents' Intentions to Engage in Fire Risk Behaviors: An Application of the Theory of Planned Behavior.

The current study examined the utility of Ajzen's Theory of Planned Behavior (TPB) in explaining adolescents' intentions to engage in fire-risk behaviors (e.g., using accelerants to start a fire), while controlling for relevant background variables. A total of 222 youth (M age=15.23years; 69% female) were recruited from public schools in rural and urban areas in the United States. Participants completed questionnaires that assessed fire and burn safety knowledge, TPB components, adolescent psychopathology, parental monitoring, and adolescent risk-taking. Using a multiple regression analysis, the TPB significantly predicted adolescents' intentions to engage in fire-risk behaviors (F(3, 193)=40.44, p<.001, R2=.386). Specifically, adolescents' attitudes toward engaging in fire-risk behaviors (ß=.46, p<.001) and the social pressure they perceived from others (e.g., parents, friends; ß=.19, p<.01) emerged as significant predictors of their intentions to engage in fire-risk behaviors. These results suggest that youth who had positive attitudes (e.g., engaging in fire-risk behaviors is fun) towards fire-risk behaviors and who believed significant others would approve of them engaging in fire-risk behaviors tended to have more intentions to engage in these behaviors. The TPB was able to account for the variance in adolescents' intentions over and above several control/background variables (e.g., SES, gender), with the exception of rebellious behavior (ß=.25, p<0.05). Results from this study can be used to inform the design of effective and targeted fire and burn prevention programs aimed specifically at adolescents.

Implementation of a Psychosocial Screener for Adults in an Outpatient Burn Clinic.

Burn injuries are significant medical traumas often resulting in substantial psychosocial distress. Early identification of psychosocial concerns is crucial to developing individualized treatments to improve psychosocial functioning. Few studies have examined the prevalence of a broad range of psychosocial concerns in an adult outpatient burn setting. In this study, they developed and implemented a screening instrument to identify patients experiencing acute psychosocial distress/risk and patients with mental health difficulties necessitating a psychology consult. The instrument assessed depression, anxiety, substance abuse, posttraumatic stress, perceived safety at home, and suicidal ideation. Adult patients (N = 178) completed the screener during an initial outpatient clinic visit. Responses on the screener were used to identify patients as "high risk" (ie, endorsing suicidal ideation and/or feeling unsafe at home), "moderate risk" (ie, endorsing no-acute mental health symptoms), or "low risk" (ie, few to no symptoms endorsed). Patients in the "high risk" category were immediately evaluated by the attending physician, who then determined whether emergency treatment was needed. Patients in the "moderate risk" category were referred to the on-site psychology team for in-person or phone consultation within 3 days of screener completion. Of the 178 individuals screened, a majority endorsed low to no psychosocial distress (N = 124; 69.7%). About one-third (N = 52) indicated moderate levels of psychosocial distress, and two patients (1.1%) endorsed acute psychosocial distress. This novel screening tool was effectively implemented in an outpatient burn clinic and demonstrates considerable promise for identifying psychosocially vulnerable patients in an adult burn survivor population.

Assessing the feasibility of implementing low-cost virtual reality therapy during routine burn care.

Burn care often involves procedures that result in significant pain experiences for patients which, in turn, can lead to poorer physical and psychological health outcomes. Distraction and virtual reality (VR) are an effective adjunct to pharmacological interventions in reducing pain. Much of the research that has demonstrated efficacy for VR in burn care has involved expensive and extensive technology. Thus, identifying cost-effective, feasible, acceptable, and effective approaches to apply distraction within routine burn care is important. The objective of this mixed-methods study was to evaluate key stakeholder (i.e., patients, providers) perceptions of feasibility, acceptability, and effectiveness for the use of low-cost VR technology during routine burn care with adult patients. Ten adult patients used VR during burn care dressing changes in an outpatient clinic setting, after which they completed a satisfaction survey and individual qualitative interview. Providers also completed a satisfaction/perception survey after each participant's care. Quantitative and qualitative results from both patient and provider perspectives consistently supported the feasibility and utility of applying low-cost VR technology in this outpatient burn clinic setting. Special considerations (e.g., aspects to consider when choosing an apparatus or application) stemming from stakeholder feedback are discussed.

Social competence in pediatric burn survivors: A systematic review.

OBJECTIVE: Youth sustaining burn injuries during childhood have dramatically increased survival rates due to improvements in medical treatment and multidisciplinary approaches to burn critical care and recovery. Despite positive advancements in burn treatment, youth sustaining such injuries may experience social deficits. Thus, this systematic review without meta-analysis investigation contributes to the growing literature on this topic by comparing social competence of pediatric burn survivors to youth without burns, and examining potential correlates of social competence among children and adolescents who have sustained burn injuries. METHOD: Fifteen empirical studies assessing social competence among youth with burns and published in the last 4 decades (i.e., 1980-2015) were identified. Data from youth, parent, and teacher perspectives related to social competence in pediatric burn survivors were extracted from studies meeting inclusion criteria. RESULTS: Results comparing social competence levels between pediatric burn survivors and youth without burns were mixed; some studies indicate that the social competence levels of pediatric burn survivors fell within the normal range, whereas other work found these youth to display social deficits. CONCLUSIONS: Implications for clinical practitioners, methodological strengths and limitations of the included research studies, and directions for future research are discussed. (PsycINFO Database Record

A Pilot Study of the Efficacy of Active Leptospermum Honey for the Treatment of Partial-Thickness Facial Burns.

OBJECTIVE: Research suggests that active Leptospermum honey (ALH) improves outcomes in patients with partial-thickness burns by enhancing healing and reepithelialization rates, as well as by protecting against antibiotic-resistant microorganisms. This study assessed the effectiveness of ALH gel on healing time, bacterial growth, patient satisfaction, and cost of treatment. DESIGN: Single-arm, prospective case series. SETTING AND PATIENTS: Seven patients (aged 7-64 years) with partial-thickness facial burns were recruited from a northeastern US burn center. INTERVENTION: All patients cleansed their wounds daily with soap and water, after which they applied ALH gel. MAIN OUTCOME MEASURES: Three physicians independently rated healing using wound photography and daily tests for the presence of exudate. Wound cultures on days 1 and 7 (±2 days) assessed bacterial growth. Patients completed a satisfaction survey at the end of treatment, and cost of treatment was calculated. MAIN RESULTS: Healing time ranged from 3 to 14 days (mean, 8.1 days). Wound cultures revealed normal bacterial growth on days 1 and 7 for all patients. Patients rated ALH gel favorably, with the most common complaint of stickiness in 5 patients. One patient experienced transient burning on application that did not interrupt treatment. Average hospital-based cost of treatment was $26.15 per patient. CONCLUSIONS: Healing time was congruent with or better than what would have been expected with standard treatment. Furthermore, despite no antibiotic treatment, wound culture results yielded no abnormal bacterial growth. Finally, patients overall reported satisfaction with treatment. The findings of this study suggest that ALH is a clinically and economically valuable treatment for partial-thickness facial burns.

Patient adherence to burn care: A systematic review of the literature.

OBJECTIVE: Few studies have been conducted on treatment adherence to burn care. Given the prevalence of burn injuries across the lifespan and the impact of proper burn care on associated morbidity, it is important to understand factors associated with regimen non-adherence in this population. The purpose of this paper is to summarize and critique all published literature on patient adherence to burn care. METHOD: With no restriction on publication date, 13 relevant articles met the following inclusion criteria: (a) utilized a sample of patients who sustained a burn injury or their medical staff; (b) focused on treatment or healthcare adherence of the patient (e.g., adherence to pressure garment therapy, physical therapy, occupational therapy, diet, dressing changes, or sunscreen use); and (c) publication written or translated into English. RESULTS: Most studies (70%) used a correlational design, while only four studies used an experimental design (either longitudinal or single subject) to assess adherence to burn care treatment. Current research suggests that burn treatment characteristics, knowledge, and beliefs are associated with adherence to burn care regimens. CONCLUSIONS: Given that adherence may vary as a function of different factors, future research should assess pediatric burn patients as a separate population, as well as investigate adherence to multiple aspects of the burn care regimen. To enhance adherence to burn care, healthcare providers should educate their patients on various treatment components and tailor these components to meet patients' goals and needs, as feasible.

Subcutaneous Injection of Percocet: A Case of Severe Soft Tissue Loss.

Prescription drug abuse ranks as the second most common class of illicit drug use in the United States, and one mechanism of opiate abuse involves intravenous injection of enteral narcotics such as oxycodone or hydrocodone. The authors describe a patient who sustained significant soft tissue necrosis after intravenously injecting a solution made from crushed enteral narcotics, with a focus on the operative course that resulted due to a delay in initial definitive treatment. The patient's wounds encompassed 8% total body surface area and covered 247 cm2. A 55-year-old female was admitted to the burn unit (West Penn Burn Center, Western Pennsylvania Hospital, Pittsburgh, PA) after she initially presented with infection and cellulitis to her bilateral upper extremities 3 weeks after intravenously injecting herself with crushed oxycodone/acetaminophen. She underwent numerous sequential operative repairs including initial debridement, placement of dermal replacement templates, and several split-thickness autografts and xenografts. Her total length of stay was 59 days, broken into an initial 47-day stay, and a subsequent 12-day readmission due to graft failure secondary to poor follow-up. As the number of prescription drug abusers rises, it is possible that an increase in attempts to intravenously abuse enteral narcotics may also rise. As such, burn centers should be prepared for the extent of potential limb necrosis and the operative treatment that may ensue.

A three-decade review of thermal injuries among the elderly at a regional burn centre.

AIM: To review trends in incidence and treatment of thermal injuries among the elderly. METHOD: A 3-year retrospective review of medical records of people aged 65 years and older admitted to our burn centre over July 2003-June 2006. RESULTS: Elderly people with burns continued to have significant comorbidities. They were often burned because they were inappropriately trying to live alone. Thus discharge was often complicated. CONCLUSIONS: At our burn centre, survival among elderly people with burns has increased, probably as a result of more sophisticated medical, surgical and nursing care, as well as more extensive rehabilitation.

Rectosigmoidectomía perineal en el tratamiento del prolapso rectal completo / Perineal rectosigmoidectomy for the treatment of complete rectal prolapse

Antecentes: El tratamiento quirúrgico del prolapso rectal completo es controvertido. Se han descrito técnicas abdominales y perineales. La rectosigmoidectomía perineal (RSP) como tratamiento en el prolapso rectal completo. Lugar de aplicación: Hospital universitario. Diseño: retrospectivo, observacional. Población: 98 pacientes con prolapso rectal completo operados entre 1985 y 2005. Método: Análisis retrospectivo y descriptivo de los pacientes con prolapso rectal completo sometidos a una RSP en un Servicio de Coloproctología. Resultados: Se realizaron 106 cirugías en 98 pacientes (79 mujeres y 19 varones, edad promedio: 78 años). El seguimiento postoperatorio fue de 11 a 101 meses. El 72 por ciento presentaban incotinencia preoperatoria. En los primeros 30 pacientes la rectosigmoidectomía perineal se realizó sin la plástica del elevador, mientras que esta se utilizó en los siguientes, como parte del procedimiento. La incontinencia mejoró en el 43 por ciento y 84 por ciento respectivamente (P = 0,01). La estadía media intrahospitalaria fue de 3,5 días. La morbilidad postoperatoria fue del 14 por ciento: 3 hemorragias postoperatorias, 2 infecciones, 1 estenosis, 4 internaciones en UTI y 5 misceláneas. La mortalidad fue nula. El porcentaje de readmisión a los 30 días fue del 3 por ciento. La recidiva fue del 13,2 por ciento (n = 15). En 8 casos se repitió el procedimiento, en 2 resección/pexia y en 1 caso rectopexia con malla. Cuatro pacientes no se reoperaron. Conclusión: La RSP es un procedimiento seguro y efectivo en el tratamiento del prolapso rectal completo. La adición de una plástica del elevador al procedimiento mejora la incontinencia que suele presentarse en estos pacientes.

Rectosigmoidectomía perineal en el tratamiento del prolapso rectal completo / Perineal rectosigmoidectomy for the treatment of complete rectal prolapse

Antecentes: El tratamiento quirúrgico del prolapso rectal completo es controvertido. Se han descrito técnicas abdominales y perineales. La rectosigmoidectomía perineal (RSP) como tratamiento en el prolapso rectal completo. Lugar de aplicación: Hospital universitario. Diseño: retrospectivo, observacional. Población: 98 pacientes con prolapso rectal completo operados entre 1985 y 2005. Método: Análisis retrospectivo y descriptivo de los pacientes con prolapso rectal completo sometidos a una RSP en un Servicio de Coloproctología. Resultados: Se realizaron 106 cirugías en 98 pacientes (79 mujeres y 19 varones, edad promedio: 78 años). El seguimiento postoperatorio fue de 11 a 101 meses. El 72 por ciento presentaban incotinencia preoperatoria. En los primeros 30 pacientes la rectosigmoidectomía perineal se realizó sin la plástica del elevador, mientras que esta se utilizó en los siguientes, como parte del procedimiento. La incontinencia mejoró en el 43 por ciento y 84 por ciento respectivamente (P = 0,01). La estadía media intrahospitalaria fue de 3,5 días. La morbilidad postoperatoria fue del 14 por ciento: 3 hemorragias postoperatorias, 2 infecciones, 1 estenosis, 4 internaciones en UTI y 5 misceláneas. La mortalidad fue nula. El porcentaje de readmisión a los 30 días fue del 3 por ciento. La recidiva fue del 13,2 por ciento (n = 15). En 8 casos se repitió el procedimiento, en 2 resección/pexia y en 1 caso rectopexia con malla. Cuatro pacientes no se reoperaron. Conclusión: La RSP es un procedimiento seguro y efectivo en el tratamiento del prolapso rectal completo. La adición de una plástica del elevador al procedimiento mejora la incontinencia que suele presentarse en estos pacientes. (AU)