Burns in the Elderly.

Burns in the elderly are a significant cause of morbidity and mortality. Frailty is an important indicator of patient health and physiologic reserve. Comorbidities and typical age-related changes significantly impact the outcomes of elderly burn patients and decisions made during their burn care. It is essential to have early and thorough discussions about the goals of care and rehabilitation plans. Physiologic changes that occur from aging cause slower wound healing and may make operative treatment more challenging, although techniques such as autographing, skin substitutes, and flaps may all play a role in treating this patient population.

Acute kidney injury in patients with burns.

Burn injury is associated with a high risk of acute kidney injury (AKI) with a prevalence of AKI among patients with burns of 9-50%. Despite an improvement in burn injury survival in the past decade, AKI in patients with burns is associated with an extremely poor short-term and long-term prognosis, with a mortality of >80% among those with severe AKI. Factors that contribute to the development of AKI in patients with burns include haemodynamic alterations, burn-induced systemic inflammation and apoptosis, haemolysis, rhabdomyolysis, smoke inhalation injury, drug nephrotoxicity and sepsis. Early and late AKI after burn injury differ in their aetiologies and outcomes. Sepsis is the main driver of late AKI in patients with burns and late AKI has been associated with higher mortality than early AKI. Prevention of early AKI involves correction of hypovolaemia and avoidance of nephrotoxic drugs (for example, hydroxocobalamin), whereas prevention of late AKI involves prevention and early recognition of sepsis as well as avoidance of nephrotoxins. Treatment of AKI in patients with burns remains supportive, including prevention of fluid overload, treatment of electrolyte disturbance and use of kidney replacement therapy when indicated.

Burn Patient Metabolism and Nutrition.

Following severe burns, patients have unique metabolic derangements that make adequate nutritional support imperative for their survival and recovery. Patients with burns have persistent and prolonged hypermetabolic states that lead to increased catabolism following injury. During rehabilitation, catabolism leads to increased muscle wasting and cachexia. Failure to adequately meet the patient's increased nutritional requirements can lead to poor wound healing, increased infections, and overall organ dysfunction. Because of these risks, adequate assessment and provision of nutritional needs are imperative to care for these patients.

Rapid development of squamous cell carcinoma at a split-thickness skin graft donor site.

The development of a Marjolin ulcer at the site of a split-thickness skin graft donor site is exceptionally rare. Here we describe the rapid development of squamous cell carcinoma at a split-thickness skin graft donor site in the setting of severe burn. We present a case of a 52-year-old male with no past medical history who presented with a 24% total body surface area burn caused by a flash flame. Four months after his initial excision and grafting, he presented for revision of a burn scar with an additional complaint of a rapidly developing skin lesion at his donor site, which arose over 2 weeks. The lesion was excised en bloc and found to be invasive squamous cell carcinoma. There are 5 previous cases of squamous cell carcinoma development at the site of split-thickness skin harvest in the setting of severe burn. While the typical Marjolin ulcer has a latency period of up to 30 years, lesions that arise in split-thickness skin graft donor sites appear to have a rapid onset of weeks to months. Squamous cell carcinoma at the site of split-thickness skin grafting is an uncommon but important sequelae of burn care.

Fungal brain abscess in a severely burned patient.

Burn patients are particularly susceptible to atypical and opportunistic infections. Here we report an unusual case of a 40-year-old previously healthy man with a 74% TBSA burn injury who developed a presumed Fusarium brain abscess. This patient had a complicated infectious course including ESBL E. coli and Elizabethkingia bacteremia and pneumonia, MRSA ventilator-associated pneumonia, Mycobacterium abscessus bacteremia, and Fusarium fungemia. After diagnosis with a fungal abscess on magnetic resonance imaging of the brain, the patient was treated with aspiration and appropriate antifungal therapies. The patient was eventually transitioned to comfort care and died on hospital day 167. This is the first published report of a Fusarium-related brain abscess since it was first reported in a case report of a burned child in 1974.

The Creation and Efforts of a Parental Task Force for Surgical Trainees.

RATIONALE AND OBJECTIONS: Surgery training often coincides with the family planning and childbearing stages of the surgeon's life. This has become especially impactful with the sharp increase in female surgical trainees. MATERIALS AND METHODS: To address important issues around family planning, our surgical department created a task force to make recommendations and create a framework as to how the department can be most supportive to surgery trainees who wish to become parents during training. RESULTS AND CONCLUSION: This article describes the efforts of the task force, which include the creation of a departmental parental handbook, a family advocacy program and a novel meeting structure designed to facilitate the successful transition to and from parental leave status.

Defining the Duty Hour for Surgical Trainees.

OBJECTIVE: Being mindful of duty hours has become an integral part of surgical training. Violations can lead to disciplinary action by the American Council for Graduate Medical Education (ACGME), including probation or even withdrawal of accreditation. It is therefore crucial to ensure these hours are accurately reported. However, as these are often self-reported by the resident, what counts as a duty hour is at the discretion of the reporter. The goal of this study is to identify what trainees and faculty include in their definitions of a duty hour. We hypothesized that there would be discrepancies in faculty versus trainee definitions of the duty hour, and that there remains an unclear understanding of which nonclinical activities contribute to surgical trainee duty hours. DESIGN: An anonymous, voluntary survey was conducted at a single institution. The survey contained 14 scenarios, and participants answered either "yes" or "no" as to if they believed the scenario should be counted within duty hour reporting. Analysis of the results included evaluating overall responses to determine which scenarios were more controversial, as well as chi square analysis comparing trainee (residents and fellows) versus faculty responses to each scenario. SETTING: This survey was performed within the Department of Surgery at the University of Texas Southwestern Medical Center, a large academic institution in Dallas, TX. PARTICIPANTS: There were 91 total faculty and trainee responses to the voluntary survey within the General Surgery Department and associated subspecialties, including 50 residents (54.9%), 4 clinical fellows (4.4%) and 37 faculty (40.7%). RESULTS: When analyzing total responses, the most controversial scenarios were taking a short period of home call (50.6% of all respondents included this as a duty hour), making a presentation for resident education (48.4%), making a presentation related to patient care (57.1%), and making a monthly call schedule (44.0%). The least controversial topic was transit to and from work (91.2% of all respondents did not include this as a duty hour). Additionally, there were statistically significant differences between trainee and faculty perceptions when it came to attending departmental curricula (96.2% trainees included as a duty hour v 81.6% faculty, p =0.02), participating in nonmandatory journal club (5.7% trainees v 23.7% faculty, p =0.01), and attending mentorship meetings (30.2% trainees v 52.6% faculty, p =0.03). CONCLUSIONS: There is no consensus as to what nonclinical activities formally count towards a duty hour. There are also significant differences identified between faculty and trainee definitions, which could have implications for duty hour reporting and ACGME violations. Further research is required to obtain a clearer picture of the surgical opinion on defining the duty hour, and hopefully this will reduce duty hour violations and better optimize surgical trainee education.

We Got Your Back: Evaluating Recovery Following Spinal Cord Injury After High-Voltage Electric Burns.

Delayed spinal cord injury (SCI) is a relatively rare consequence of high voltage electrical burns, but it holds significant implications for patient quality of life. Due to the uncommon nature of delayed SCI and variable time of onset following injury, providers are currently unable to provide a prognosis for functional recovery and optimize a therapy process tailored to treat this patient populace. In this study, we aim to better map the pattern of recovery in these patients to better inform future rehabilitation practices. A retrospective chart review of five patients who experienced delayed SCI secondary to an electrical burn was conducted. The majority of patients displayed an upward trajectory in motor function following acute hospitalization and inpatient rehabilitation, with four of the five patients able to achieve complete motor strength in multiple extremities. In addition, rehabilitation was shown to have a noticeable impact in improving functional independence in tasks related to nursing. In conclusion, the clinical and functional outcomes of these delayed SCI patients point to the need for multidisciplinary management following injury and highlight the importance of early rehabilitation in regaining function.

Little Utility of Fungal Blood Cultures in Surgical and Burn Intensive Care Units.

Critically ill patients are at risk for fungal infections, but there is a paucity of data regarding the clinical utility of dedicated fungal blood cultures to detect such infections. A retrospective review was conducted of patients admitted to the surgical and burn intensive care units at Parkland Memorial Hospital between 1 January 2013 and 31 December 2017 for whom blood cultures (aerobic, anaerobic, and/or fungal cultures) were sent. A total of 1,094 aerobic and anaerobic blood culture sets and 523 fungal blood cultures were sent. Of the aerobic and anaerobic culture sets, 42/1,094 (3.8%) were positive for fungal growth. All fungal species cultured were Candida. Of the fungal blood cultures, 4/523 (0.76%) were positive for growth. Fungal species isolated included Candida albicans, Aspergillus fumigatus, and Histoplasma capsulatum. All 4 patients with positive fungal blood cultures were on empirical antifungal therapy prior to results, and the antifungal regimen was changed for 1 patient based on culture data. The average duration to final fungal culture result was 46 days, while the time to preliminary results varied dramatically. Two of the four patients died prior to fungal culture results, thereby rendering the culture data inconsequential in patient care decisions. This study demonstrates that regular aerobic and anaerobic blood cultures sets are sufficient in detecting the most common causes of fungemia and that results from fungal cultures rarely impact treatment management decisions in patients in surgical and burn intensive care units. There is little clinical utility to routine fungal cultures in this patient population. IMPORTANCE This study demonstrates that regular aerobic and anaerobic blood culture sets are sufficient in detecting the most common causes of fungemia, and thus, sending fungal blood cultures for patients in surgical and burn intensive care units is not a good use of resources.

Skeletal muscle wasting after a severe burn is a consequence of cachexia and sarcopenia.

Muscle wasting is common and persistent in severely burned patients, worsened by immobilization during treatment. In this review, we posit two major phenotypes of muscle wasting after severe burn, cachexia and sarcopenia, each with distinguishing characteristics to result in muscle atrophy; these characteristics are also likely present in other critically ill populations. An online search was conducted from the PubMed database and other available online resources and we manually extracted published articles in a systematic mini review. We describe the current definitions and characteristics of cachexia and sarcopenia and relate these to muscle wasting after severe burn. We then discuss these putative mechanisms of muscle atrophy in this condition. Severe burn and immobilization have distinctive patterns in mediating muscle wasting and muscle atrophy. In considering these two pathological phenotypes (cachexia and sarcopenia), we propose two independent principal causes and mechanisms of muscle mass loss after burns: (1) inflammation-induced cachexia, leading to proteolysis and protein degradation, and (2) sarcopenia/immobility that signals inhibition of expected increases in protein synthesis in response to protein loss. Because both are present following severe burn, these should be considered independently in devising treatments. Discussing cachexia and sarcopenia as independent mechanisms of severe burn-initiated muscle wasting is explored. Recognition of these associated mechanisms will likely improve outcomes.

Resident Engagement in a Wellness Program in a Large Academic Residency: A Follow-Up After Two Years of Wellness.

INTRODUCTION: The rate of burnout among residents has reached an alarming level and negatively impacts learning, attrition, and patient care. We implemented a comprehensive Surgery Resident Wellness Program in a large academic program and aimed to assess the degree this initiative improved resident burnout based on validated burnout and well-being models utilizing voluntary surveys. MATERIALS AND METHODS: A voluntary survey was sent to surgical residents and included the Maslach Burnout Inventory and The Psychological General Well-Being Index. These were graded according to the respective validated scale for each test. The survey was administered prior to establishing a wellness program, and at 6 month- and 24 month-intervals following its establishment. These data were analyzed using univariate analysis based on survey data from each of the time points. RESULTS: The survey had a 51% response rate. The baseline, 6-month, and 24-month mean scores for MBI personal accomplishment were 32.80, 32.91, and 35.57, emotional exhaustion was 23.48, 23.0, and 24.42, and depersonalization were 10.94, 9.54, and 11.11. Resident burnout was present in 16 of 31 (51.61%), 14 of 33 (42.42%), and 12 of 27 (44.44%) residents at each time point. The rate of change in resident burnout was -17.8% at 6 months and -13.9% at 24 months. The averaged PGWBI global scores were 66, 73, and 83 among the participants who took the survey at each time interval. CONCLUSIONS: Conclusion Implementation of a structured wellness program was associated with a decrease in resident burnout and an increase in overall resident wellness.

The Fuel Gauge: A Simple Tool for Assessing General Surgery Resident Well-Being.

OBJECTIVE: Resident well-being is an increasingly relevant issue in medical education; however, there is no consensus on how to best measure well-being. The "fuel gauge," is a simple, easy-to-use tool developed to measure resident well-being and previously applied in an Internal Medicine Residency Program at our institution. The current study sought to evaluate its acceptability and usefulness in a surgery program. DESIGN: Weekly fuel gauge data was retrospectively collected from August 2017 through December 2018 along with resident Postgraduate Year designations. SETTING: This study was conducted at a single, large general surgery residency program that rotates through a variety of hospitals, including a University hospital, a large county hospital, a Veterans Affairs hospital, and a freestanding Children's hospital. PARTICIPANTS: Categorical general surgery residents at every level of training as well as preliminary interns and off service intern rotators from urology, oral and maxillofacial surgery, and otolaryngology were eligible for the study. Fuel gauge submissions which did not denote a score were excluded from analysis. RESULTS: Out of 130 residents, 103 (79.2%) completed at least 1 fuel gauge assessment with a weekly mean response rate of 41.5%. Low scores were submitted by 39.8% of resident participants. Narrative feedback was provided in 6.2% of submissions with increased length associated with decreased fuel gauge score. CONCLUSIONS: The fuel gauge was well accepted by a large general surgery program with no decline in participation rates over the study period. The tool provided residents with a direct line of communication with their program's administration, and a feasible way for the program director's office to monitor and identify residents who were struggling with regard to their well-being.

Muscle Homeostasis Is Disrupted in Burned Adults.

Severe burn leads to substantial skeletal muscle wasting that is associated with adverse outcomes and protracted recovery. The purpose of our study was to investigate muscle tissue homeostasis in response to severe burn. Muscle biopsies from the right m. lateralis were obtained from 10 adult burn patients at the time of their first operation. Patients were grouped by burn size (total body surface area of <30% vs ≥30%). Muscle fiber size and factors of cell death and muscle regeneration were examined. Muscle cell cross-sectional area was significantly smaller in the large-burn group (2174.3 ± 183.8 µm2 vs 3687.0 ± 527.2 µm2, P = .04). The expression of ubiquitin E3 ligase MuRF1 and cell death downstream effector caspace 3 was increased in the large-burn group (P < .05). No significant difference was seen between groups in expression of the myogenic factors Pax7, MyoD, or myogenin. Interestingly, Pax7 and proliferating cell nuclear antigen (PCNA) expression in muscle tissue were significantly correlated to injury severity only in the smaller-burn group (P < .05). In conclusion, muscle atrophy after burn is driven by apoptotic activation without an equal response of satellite cell activation, differentiation, and fusion.

Administration of Tumescence in Pediatric Burn Patients Causes Significant Hypertension.

The effects of injecting tumescence containing phenylephrine in pediatric burn patients are unknown, but anecdotally our clinicians note a high incidence of hypertension requiring treatment. This study sought to determine whether tumescence with phenylephrine was associated with hypertension requiring treatment in our pediatric burn patients. This was a retrospective cohort study of pediatric burn patients who underwent tangential excision with split-thickness autografting, excision alone, or autografting alone from 2013 to 2017. Records were reviewed for hypertensive episodes, defined as ≥2 consecutive blood pressure readings that were >2 SD above normal. Published intraoperative age- and sex-adjusted standards were used to define reference values. Parametric and nonparametric tests were used when appropriate. In total, 258 operations were evaluated. Mean patient age was 7.6 ± 5.2 years, and 64.7% were male. Patients were predominately white (69.8%). Overall, there was a 62.8% incidence of hypertension. On univariate logistic regression analysis, duration of operation, estimated blood loss, treated TBSA, and weight-adjusted volume of tumescence were significant predictors of intraoperative hypertension (P < .01). On multivariate analysis, weight-adjusted volume of tumescence alone was significantly associated with the presence of hypertension with an odds ratio of 2.0 (95% confidence interval: 1.33-3.04). Of the 162 operations which exhibited at least one episode of significant hypertension, 128 cases (79%) were treated. Intraoperative administration of phenylephrine-containing tumescence in pediatric burn patients is associated with clinically significant hypertension requiring treatment. This practice should be conducted with caution in pediatric burn operations until its clinical implications are defined.

Serum Level of Musclin Is Elevated Following Severe Burn.

Muscle wasting induced by severe burn worsens clinical outcomes is associated with hyperglycemia. A novel muscle-specific secretory factor, musclin, was reported to regulate glucose metabolism with a homologous sequence of natriuretic peptides. The purpose of the study was to investigate musclin expression in response to burn injury in both human and animal models. Serum was collected from 13 adult burn patients and circulating levels of musclin protein were measured via elisa. The cytokine profile was measured by Bio-Plex multiple immunoassay. Following the clinical study, we used a burn rat model with 40% TBSA to study the time course of musclin expression till day 14. Rat serum and muscle tissue sample were harvested. Finally, an in vitro study was applied to investigate whether the muscle cell C2C12 myoblast expressed musclin under 10% burn serum stimulation. Pearson analysis showed that there was a significant positive correlation of musclin expression to total body surface area of burn in patients (P &= .038). Musclin expression was significantly positively correlated with IL-4, IL-7, IL-12, and IL-13 in burn patients' serum (P < .05). In the animal study, we found that the musclin level evaluated at 6 hours and 1 day in burn rat serum (P < .05). In vitro, musclin mRNA expression significantly increased with burn serum stimulation at 24 hours (P < .05). In conclusion, serum level of musclin elevated both in human patients and burn animals; musclin was correlated with the severity of burn injury as well as with an elevated cytokine profile in patients; burn serum-stimulated musclin expression in vitro further identified the resource of musclin expression after burn.

Treating Hypertrophic Burn Scar With 2940-nm Er:YAG Laser Fractional Ablation Improves Scar Characteristics as Measured by Noninvasive Technology.

Their group previously demonstrated high-patient satisfaction for the treatment of hypertrophic burn scar (HBS) with the erbium: yttrium aluminum garnet (Er:YAG) laser, but this and other literature supporting the practice suffer from a common weakness of a reliance on subjective assessments by patients or providers. Herein, they sought to prospectively study the effects of Er:YAG fractional ablation on HBS using noninvasive, objective technologies to measure outcomes. Patients with HBS had identical regions of scar designated for treatment by the Er:YAG laser (TREAT) or to be left untreated (CONTROL). They prospectively collected scar measurements of TREAT and CONTROL regions preoperatively, 3 weeks, and 3 months after Er:YAG treatment. Scar measurements included viscoelastometry, transepidermal water loss, optical coherent tomography, and high-frequency ultrasound. Outcomes were measured for the aggregate difference between the TREAT group vs the CONTROL group, as well as within each group in isolation. Seventeen patients were seen preoperatively, followed by n = 15 at 3 weeks and n = 11 at 3 months. A mixed-model repeated measures analysis showed no significant effect of fractional ablation when comparing the overall TREAT group measurements with those of the CONTROL group. However, when considered as within-group measurements, TREAT scars showed significant improvement in viscoelastic deformity (P = .03), elastic deformity (P = .004), skin roughness (P = .05), and wrinkle depth (P = .04) after fractional ablation, whereas CONTROL scars showed no such within-group changes. HBS treated by the Er:YAG laser showed objective improvements, whereas no such changes were seen within the untreated scars over the same time frame.

Analysis of operating room efficiency between a hospital-owned ambulatory surgical center and hospital outpatient department.

BACKGROUND: Ambulatory surgery centers (ASCs) are frequently utilized; however some ambulatory procedures may be performed in hospital outpatient departments (HOPs). Our aim was to compare operating room efficiency between our ASC and HOP. METHODS: We reviewed outpatient general surgery procedures performed at our ASC and HOP. Total case time was divided into five components: ancillary time, procedure time, exit time, turnover time, and nonoperative time. RESULTS: Overall, 220 procedures were included (114 ASC, 106 HOP). Expressed in minutes, the mean turnover time (29.8 ±â€¯9.6 vs. 24.5 ±â€¯12.7; p < 0.01), ancillary time (32.2 ±â€¯7.0 vs. 22.2 ±â€¯4.5; p < 0.01), procedure time (77.4 ±â€¯44.9 vs. 56.2 ±â€¯23.0 p < 0.01), exit time (11.8 ±â€¯4.4 vs. 8.5 ±â€¯4.3; p < 0.01), and nonoperative time (62.9 ±â€¯21.9 vs. 48.7 ±â€¯15.0; p < 0.01) were longer at the HOP than at the ASC. CONCLUSION: ASC outpatient procedures are more efficient than those performed at our HOP. A system evaluation of our HOP operating room efficiency is necessary.

Assessment of general surgery resident study habits and use of the TrueLearn question bank for American Board of Surgery In-Training exam preparation.

BACKGROUND: Little information exists on the value of online question banks in preparing residents for the American Board of Surgery In-Training Examination (ABSITE). METHODS: We reviewed surgical residents' use of an online question bank (TrueLearn) and compared it to their ABSITE performance. RESULTS: The 2016-2017 records of 44 PGY 2-5 general surgery residents were examined. The total number of TrueLearn questions answered significantly correlated (p < 0.05) with correct answers and percentile rank on the 2017 ABSITE. If a resident was to complete the entire online TL question bank consisting of 1000 questions, the overall percentage correct and overall percentile on the ABSITE is estimated to increase by 3% and 20%, respectively. CONCLUSIONS: The use of the TrueLearn question bank is associated with an improved percentage of ABSITE questions answered correctly and improved PGY percentile scores.

Prospective Analysis of Operating Room and Discharge Delays in a Burn Center.

Delays to the operating room (OR) or discharge (DC) lead to longer lengths of stay and increased costs. Surprisingly, little work has been done to quantify the number and cost of delays for inpatients to the OR, and to DC to outpatient status. They reviewed their burn admissions to determine how often a patient experiences delays in healthcare delivery. Data for all burn admissions were prospectively collected from 2014 to 2016. A quality improvement filter was created to define acceptable parameters for patient throughput. Every hospital day was labeled as 1) No delay, 2) Operation, 3) Delay to the OR, or 4) Delay to DC. They had 1633 admissions: 432 ICU admissions (26%) and 1201 floor admissions (74%). Six hundred fifteen patients (37.7%) received an operation. Patients with delays included 331 with OR delays (20.3%) and 503 with DC delays (30.8%). Average delay days included (Mean ± SD): OR delay days = 4.7 ± 6.2 and DC delay days = 4.1 ± 4.4. Total number of hospital days was 13,009, divided into 1616 OR delay days (12%) and 2096 DC delay days (16%). Significant OR delays were due to patient unstable for OR (n = 387 [24%]), OR space availability (n = 662 [41%]), indeterminate wound depth (n = 437 [27%]), and donor site availability (n = 83 [5%]). Significant DC delays were due to medical goals not reached (n = 388 [19%]), pain control and wound care (n = 694 [33%]), PT/OT clearance (n = 168 [8.0%]), and DC placement delays (n = 754 [36%]). Costs for OR and DC delays ranged between US$1,000,000 and US$5,000,000. Costs of increasing OR capacity and/or additional social work ancillary staff can be justified through millions of dollars of savings annually.