Is the Use of Routine Echocardiograms Warranted in Large Pediatric Burns?

Cardiac dysfunction can develop in large pediatric burns during the acute and recovery phase. When occurring in this population, the cardiac abnormality appears as left ventricular dysfunction or dilated cardiomyopathy. Recent studies have demonstrated perioperative and long-term cardiac dysfunction resulting in longer hospital stays for patients over 40% total body surface area. The objective of this study was to assess if early use of echocardiograms in large burns would allow for early recognition of patients at risk for cardiac dysfunction. Pediatric burn patients ages 0 to 18 years who sustained a burn injury of 30% TBSA or more or developed cardiac dysfunction during hospital course were evaluated. Echocardiograms were obtained upon admission with monthly repeats until three normal studies were attained or the patient was discharged and when symptomatic. Of the 130 acute burn patients admitted during 7/2017 to 10/2018, 10 patients met criteria for enrollment in this study. The average age was 5 years (0.8-10 years), 70% were males and 90% sustained flame injuries.Total TBSA average was 45% (24-70%) with average full-thickness burns of 33% (0-67%). Twenty echocardiogram studies were obtained. One patient with 25% TBSA burn, demonstrated severe left ventricular dysfunction with an ejection fraction (EF) of 25% from post-arrest myocardial stunning. Repeat echocardiogram studies demonstrated full recovery with normal EF. The remaining patients, despite large TBSA injuries, did not exhibit any abnormalities on echocardiogram examinations. No cardiac interventions were required. Use of echocardiograms is best performed on symptomatic burn patient populations.

Measuring the impact of burn injury on the parent-reported health outcomes of children 1-to-5 years: Item pool development for the Preschool1-5 Life Impact Burn Recovery Evaluation (LIBRE) Profile.

Modern, reliable, and valid outcome measures are essential to understanding the health needs of young children with burn injuries. Burn-specific and age-appropriate legacy assessment tools exist for this population but are hindered by the limitations of existing paper-based instruments. The purpose of this study was to develop item pools comprised of questions appropriate for children aged 1-5 with burn injuries. Item development was based on a framework provided by previous work to develop the Preschool Life Impact Burn Recovery Evaluation (LIBRE) Conceptual Model. The Preschool LIBRE Conceptual Model work established four sub-domains of functioning for children with burns aged 1-5. Item development involved a systematic literature review, a qualitative item review process with clinical experts, and parent cognitive interviews. Four item pools were established: (1) communication and language development; (2) physical functioning; (3) psychological functioning and (4) social functioning for preschool-aged children with burn injuries. We selected and refined candidate items, recall periods, survey instructions, and response option choices through clinical and parental feedback during the qualitative review and cognitive interview processes. Item pools are currently being field-tested as part of the process to calibrate and validate the Preschool1-5 LIBRE Computer Adaptive Test (CAT) Profile.

Efficacy of Topical Antimicrobial Agents Against Bacterial Isolates From Burn Wounds.

Topically applied antimicrobials are key to the prevention of infection and mortality in the acute burn population. The purpose of this study was to determine the in vitro effectiveness of commercially available topical antimicrobials, as well as topical preparations that were compounded in our burn care institution. One-hundred twenty microorganisms were tested against these topical antimicrobials and in vitro effectiveness was observed. Results showed that compounded preparations of 1:1:1 + Double Antibiotic (1 part bacitracin: 1 part silver sulfadiazine: 100,000 units/g nystatin + 5 mg/g neomycin sulfate + 500 units/g polymyxin B) and 3:1 + Double Antibiotic (3 part bacitracin: 1 part silver sulfadiazine + 5mg/g neomycin sulfate + 500 units/g polymyxin B) were effective against 100% of the isolates tested. Other topical agents showed moderate effectiveness, thus demonstrating the need for multiple topical agents to reach a broad spectrum of microorganisms. However, the development of topical antimicrobial resistance needs further study.

Impact of scale-aware deep convection on the cloud liquid and ice water paths and precipitation using the Model for Prediction Across Scales (MPAS-v5.2).

The cloud liquid water path (LWP), ice water path (IWP), and precipitation simulated with uniform- and variable-resolution numerical experiments using the Model for Prediction Across Scales (MPAS) are compared against Clouds and the Earth's Radiant Energy System (CERES) and Tropical Rainfall Measuring Mission data. Our comparison between monthly-mean model diagnostics and satellite data focuses on the convective activity regions of the tropical Pacific Ocean, extending from the Tropical Eastern Pacific Basin where trade wind boundary layer clouds develop to the Western Pacific Warm Pool characterized by deep convective updrafts capped with extended upper-tropospheric ice clouds. Using the scale-aware Grell-Freitas (GF) and Multiscale Kain-Fritsch (MSKF) convection schemes in conjunction with the Thompson cloud microphysics, uniform-resolution experiments produce large biases between simulated and satellite-retrieved LWP, IWP, and precipitation. Differences in the treatment of shallow convection lead the LWP to be strongly overestimated when using GF, while being in relatively good agreement when using MSKF compared to CERES data. Over areas of deep convection, uniform- and variable-resolution experiments overestimate the IWP with both MSKF and GF, leading to strong biases in the top-of-the-atmosphere longwave and shortwave radiation relative to satellite-retrieved data. Mesh refinement over the Western Pacific Warm Pool does not lead to significant improvement in the LWP, IWP, and precipitation due to increased grid-scale condensation and upward vertical motions. Results underscore the importance of evaluating clouds, their optical properties, and the top-of-the-atmosphere radiation budget in addition to precipitation when performing mesh refinement global simulations.

Measuring the Impact of Burn Injury on the Parent-Reported Health Outcomes of Children 1 to 5 Years: A Conceptual Framework for Development of the Preschool Life Impact Burn Recovery Evaluation Profile CAT.

Due to the rapid developmental growth in preschool-aged children, more precise measurement of the effects of burns on child health outcomes is needed. Expanding upon the Shriners Hospitals for Children/American Burn Association Burn Outcome Questionnaire 0 to 5 (BOQ0-5), we developed a conceptual framework describing domains important in assessing recovery from burn injury among preschool-aged children (1-5 years). We developed a working conceptual framework based on the BOQ0-5, the National Research Council and Institute of Medicine's Model of Child Health, and the World Health Organization's International Classification of Functioning, Disability, and Health for Children and Youth. We iteratively refined our framework based on a literature review, focus groups, interviews, and expert consensus meetings. Data were qualitatively analyzed using methods informed by grounded theory. We reviewed 95 pediatric assessments, conducted two clinician focus groups and six parent interviews, and consulted with 23 clinician experts. Three child health outcome domains emerged from our analysis: symptoms, functioning, and family. The symptoms domain describes parents' perceptions of their child's pain, skin-related discomfort, and fatigue. The functioning domain describes children's physical functioning (gross and fine motor function), psychological functioning (internalizing, externalizing, and dysregulation behavior; trauma; toileting; resilience), communication and language development (receiving and producing meaning), and social functioning (connecting with family/peers, friendships, and play). The family domain describes family psychological and routine functioning outcomes.

Incorporation of 3D stereophotogrammetry as a reliable method for assessing scar volume in standard clinical practice.

Significant disfigurement and dysfunction is caused by hypertrophic scarring, a prevalent complication of burn wounds. A lack of objective tools in the assessment of scar parameters makes evaluation of scar treatment modalities difficult. 3D stereophotogrammetry, obtaining measurements from 3D photographs, represents a method to quantitate scar volume, and a 3D camera may have use in clinical practice. To validate this method, scar models were created and photographed with a 3D camera. Measurements from 3D image analysis of these scar models were compared to physical measurements of scar model volume. Reliability of 3D image analysis was assessed with both scar models and burn patient scars. Measurements of scar models by two independent observers were compared to determine inter-rater reliability, and measurements from 3D images of burn patient hypertrophic scars were compared to determine the consistency of the method between observers. The time taken for patient photography was recorded. No significant differences were found between the two methods of volume calculation (p = 0.89), and a plot of the differences showed agreement between the methods. The correlation coefficient between the two observers' measurements of scar model volume was 0.92, and the intra-class correlation coefficient for patient scar volume was 0.998, showing good reliability. The time required to capture 3D photographs ranged from 2 to 6 min per patient, showing the potential for this tool to be efficiently incorporated into clinical practice. 3D stereophotogrammetry is a valid method to reliably measure scar volume and may be used to objectively measure efficacy of scar treatment modalities to track scar development and resolution.

Usefulness of a Novel System for Feedback of Patient-Reported Outcome Measures in Children Recovering From Burns.

The Burn Outcomes Questionnaire for children ages 5-18 years (BOQ5-18) is a widely used, reliable, and valid parent-reported outcome measure designed to assess children's recovery from burn injuries in 12 physical and psychosocial domains. This study evaluated the feasibility, acceptability, and usefulness of a feedback system that delivered BOQ and Pediatric Symptom Checklist (PSC-17; a widely used measure of psychosocial functioning) results to burn care clinicians prior to an outpatient appointment or a postoperative surgical encounter. The BOQ and the PSC-17 were administered to the parents of 147 children receiving outpatient or surgical care in two pediatric burn hospitals. Clinician and parent perceptions of the feedback system were evaluated using debriefing questionnaires. Over half of all patients were at-risk on at least one BOQ subscale, and risk on three or more BOQ domains was significantly associated with a higher likelihood of poor psychological scores on the PSC-17 (P < .001). Significant differences in BOQ scores were found between the two hospital sites on four BOQ subscales, three related to physical ability and one to psychosocial well-being. Parent ratings of the feedback system were positive, with 90% of parents in both settings agreeing that the BOQ tablet experience was easy and helpful. Clinician attitudes differed across the two settings with more positive clinician ratings of the system in the outpatient setting (P < .001). Clinician interviews revealed that the data was especially useful in bringing to light psychosocial aspects of functioning relevant to long-term recovery from burn injuries.

Prevalence and Risk Factors for Hypertrophic Scarring of Split Thickness Autograft Donor Sites in a Pediatric Burn Population.

TITLE: Prevalence and Risk Factors for Hypertrophic Scarring of Split Thickness Autograft Donor Sites in a Pediatric Burn Population. OBJECTIVE: The split-thickness autograft remains a fundamental treatment for burn injuries; however, donor sites may remain hypersensitive, hyperemic, less pliable, and develop hypertrophic scarring. This study sought to assess the long-term scarring of donor sites after pediatric burns. METHODS: A retrospective review of pediatric burn patients treated at a single institution (2010-2016) was performed. Primary outcomes were prevalence of donor site hypertrophic scarring, scarring time course, and risk factor assessment. RESULTS: 237 pediatric burn patients were identified. Mean age at burn was 7 yrs., mean %TBSA was 26% with 17% being Full Thickness. Mean follow-up was 2.4 yrs. Hypertrophic scarring was observed in 152 (64%) patients with 81 (34%) patients having persistent hypertrophic scarring through long-term follow-up. Patient-specific risk factors for hypertrophic scarring were Hispanic ethnicity (P=0.03), increased %TBSA (P=0.03), %Full Thickness burn (P=0.02) and total autograft amount (P=0.03). Donor site factors for hypertrophic scarring were longer time to epithelialization (P<0.0001), increased donor site harvest depth (P<0.0001), autografts harvested in the acute burn setting (P=0.008), and thigh donor site location (vs. all other sites; P<0.0001). The scalp, arm, foot, and lower leg donor sites (vs. all other sites) were less likely to develop HTS (P<0.0001, 0.02, 0.005, 0.002, respectively), along with a history of previous donor site harvest (P=0.04). CONCLUSIONS: Hypertrophic scarring is a prominent burden in donor site wounds of pediatric burn patients. Knowledge of pertinent risk factors can assist with guiding management and expectations.

Reducing Door-to-Needle Times for Ischaemic Stroke to a Median of 30 Minutes at a Community Hospital.

BACKGROUND: Alteplase is an effective treatment for ischaemic stroke patients, and it is widely available at all primary stroke centres. The effectiveness of alteplase is highly time-dependent. Large tertiary centres have reported significant improvements in their door-to-needle (DTN) times. However, these same improvements have not been reported at community hospitals. METHODS: Red Deer Regional Hospital Centre (RDRHC) is a community hospital of 370 beds that serves approximately 150,000 people in their acute stroke catchment area. The RDRHC participated in a provincial DTN improvement initiative, and implemented a streamlined algorithm for the treatment of stroke patients. During this intervention period, they implemented the following changes: early alert of an incoming acute stroke patient to the neurologist and care team, meeting the patient immediately upon arrival, parallel work processes, keeping the patient on the Emergency Medical Service stretcher to the CT scanner, and administering alteplase in the imaging area. Door-to-needle data were collected from July 2007 to December 2017. RESULTS: A total of 289 patients were treated from July 2007 to December 2017. In the pre-intervention period, 165 patients received alteplase and the median DTN time was 77 minutes [interquartile range (IQR): 60-103 minutes]; in the post-intervention period, 104 patients received alteplase and the median DTN time was 30 minutes (IQR: 22-42 minutes) (p < 0.001). The annual number of patients that received alteplase increased from 9 to 29 in the pre-intervention period to annual numbers of 41 to 63 patients in the post-intervention period. CONCLUSION: Community hospitals staffed with community neurologists can achieve median DTN times of 30 minutes or less.

CONTEXTE: L'altéplase est un traitement efficace dans le cas de patients victimes d'AVC ischémiques et demeure largement disponible dans les centres de soins de niveau primaire dédiés aux AVC. Cela dit, son efficacité dépend fortement des délais en fonction desquels on peut l'administrer. À cet égard, les centres de soins de niveau tertiaire ont fait état d'importantes améliorations en ce qui regarde leurs délais entre l'arrivée de patients et l'injection d'un traitement thrombolytique. Toutefois, il semble que de telles améliorations n'ont pas été signalées dans les hôpitaux communautaires. MÉTHODES: Le Red Deer Regional Hospital Centre (RDRHC) est un hôpital communautaire de 370 lits qui dessert approximativement 150 000 personnes dans sa zone d'attraction. Cet hôpital a participé à une initiative provinciale de réduction des délais mentionnés ci-dessus. Pour ce faire, il a mis au point un algorithme simplifié en vue du traitement de patients victimes d'AVC. Au cours de cette période d'intervention, les mesures de changement suivantes ont donc été adoptées : des alertes précoces transmises à un neurologue et aux équipes soignantes au moment de l'admission de patients victimes d'AVC aigus ; des rencontres immédiates avec les patients, et ce, dès leur arrivée à l'hôpital ; des processus de travail menés de façon parallèle ; le maintien des patients dans une civière d'ambulance jusqu'à temps qu'on puisse les conduire à un tomodensitomètre ; enfin, le fait d'administrer l'altéplase en fonction de la zone atteinte révélée par imagerie. Soulignons enfin que nos données en matière de réduction des délais ont été collectées de juillet 2007 à décembre 2017. RÉSULTATS: Au total, 289 patients ont été traités durant cette période. Au cours de la période antérieure à l'initiative évoquée précédemment, 165 patients ont bénéficié d'un traitement à l'altéplase ; les délais médians entre l'arrivée des patients et l'injection de ce médicament thrombolytique étaient alors de 77 minutes (EI : 60-103 minutes). Une fois mise en place l'initiative de réduction des délais, 104 patients ont reçu un traitement à l'altéplase ; cette fois, les délais médians du RDRHC étaient de 30 minutes (EI : 22-42 minutes ; p < 0,001). Fait à noter, le nombre annuel de patients ayant bénéficié de l'altéplase est passé de 9 à 29 durant la période pré-initiative et de 41 à 63 lors de la période post-initiative. CONCLUSION: Dans le cas des hôpitaux communautaires disposant de neurologues réguliers, il est possible de parvenir à des délais de 30 minutes ou moins entre l'arrivée de patients et l'injection d'un traitement thrombolytique.

Randomized, Paired-Site Comparison of Autologous Engineered Skin Substitutes and Split-Thickness Skin Graft for Closure of Extensive, Full-Thickness Burns.

Stable closure of full-thickness burn wounds remains a limitation to recovery from burns of greater than 50% of the total body surface area (TBSA). Hypothetically, engineered skin substitutes (ESS) consisting of autologous keratinocytes and fibroblasts attached to collagen-based scaffolds may reduce requirements for donor skin, and decrease mortality. ESS were prepared from split-thickness skin biopsies collected after enrollment of 16 pediatric burn patients into an approved study protocol. ESS and split-thickness autograft (AG) were applied to 15 subjects with full-thickness burns involving a mean of 76.9% TBSA. Data consisted of photographs, tracings of donor skin and healed wounds, comparison of mortality with the National Burn Repository, correlation of TBSA closed wounds with TBSA full-thickness burn, frequencies of regrafting, and immunoreactivity to the biopolymer scaffold. One subject expired before ESS application, and 15 subjects received 2056 ESS grafts. The ratio of closed wound to donor areas was 108.7 ± 9.7 for ESS compared with a maximum of 4.0 ± 0.0 for AG. Mortality for enrolled subjects was 6.25%, and 30.3% for a comparable population from the National Burn Repository (P < .05). Engraftment was 83.5 ± 2.0% for ESS and 96.5 ± 0.9% for AG. Percentage TBSA closed was 29.9 ± 3.3% for ESS, and 47.0 ± 2.0% for AG. These values were significantly different between the graft types. Correlation of % TBSA closed with ESS with % TBSA full-thickness burn generated an R value of 0.65 (P < .001). These results indicate that autologous ESS reduce mortality and requirements for donor skin harvesting, for grafting of full-thickness burns of greater than 50% TBSA.

Developing a specialist-nurse-led 'COPD in-reach service'.

AIM: To develop and implement a respiratory clinical-nurse-specialist-led chronic obstructive pulmonary disease (COPD) 'in-reach service' for an emergency admission unit within a large acute county hospital. METHOD: Data collected during the service development were compared with existing data when no COPD in-reach service was available. Data were compared on average length of stay, readmission rates, 'early assisted discharge' and patient experience. FINDINGS: The COPD in-reach service reduced average length of stay for COPD patients by 2.53 days and readmission rates were reduced by an average of 4.5 per month; 17% of patients were discharged on an early assisted discharge scheme, and overall patients felt more prepared and ready for discharge. CONCLUSION: The COPD in-reach service has been proven to be of great benefit both financially and in terms of patient experience.

Burn center journal club promotes clinical research, continuing education, and evidence-based practice.

The purpose of this study was to characterize the structure, policy, implementation, and outcome measures of a burn team journal club to assess its effectiveness in promoting multidisciplinary education relative to research competency, clinical knowledge, and evidence-based practice. After 2 years of a new multidisciplinary format, an anonymous quality assurance survey was distributed to staff members of a regional pediatric burn center to evaluate the impact of the journal club on clinical and research indicators. The 24 journal club meetings evaluated in this study included a variety of topics, among which were wound healing, infection, nutrition, metabolism, sleep, medications, alternative medicine, research compliance, and child abuse. The speakers included a variety of hospital personnel: 26% researchers, 23% physicians, 20% registered nurses, and 31% other disciplines and attendance mean was 29 participants per session (range 17-50). Survey results from 30 respondents indicated that 100% judged the program to be valuable to personal educational needs and 83% indicated that format did not warrant change. According to self-report data, the journal club enhanced medical knowledge (90%), patient care (73%), research competency (70%), critical thinking (63%), and evidence-based practice (63%). Results indicate that the journal club program was well received by participants, and promoted enhanced knowledge and improved patient care. In the future, barriers to research initiatives and integration of research findings into practice warrant follow-up study. Journal club should be incorporated into the learning curriculum of burn practitioners as a means to promote critical thinking, research competency, and evidence-based clinical practice.

Procalcitonin in pediatric burn patients: an early indicator of sepsis?

To determine whether changes in procalcitonin (PCT) could be used to predict the onset of sepsis, daily PCT levels were monitored in 20 burned children. Analysis indicated a PCT rise of 5 ng/ml or greater as the best indication of sepsis. We compared the surgeons' determination of sepsis, which was based on changes in platelet count, C-reactive protein (CRP), and other clinical manifestations, with the prediction of sepsis from PCT. There were 26 septic episodes and 36 nonseptic episodes in the 20 patients. PCT results were classified as to true positives, false positives, true negatives, and false negatives. As an indicator of sepsis, the PCT assay had a sensitivity of 42%, a specificity of 67%, and an efficiency of 57%. Even when the assay correctly identified sepsis, the determination was made an average of 0.8 days after the surgeon had already made the diagnosis based on CRP and/or platelet count. We conclude that PCT is not as effective as CRP and/or platelet count in the early detection of sepsis in burned children.