A Comparison of Racial and Ethnic Disparities in Complications Following Burn Injury in Adult Patients.

Burn injury contributes to significant morbidity and mortality in the United States. Despite an increased focus on racial and ethnic disparities in healthcare, there remains a critical knowledge gap in our understanding of the effect of these disparities on complications experienced by burn patients. The American Burn Association's National Burn Repository data were reviewed from 2010-2018. Information regarding demographics, burn mechanism and severity, complications, and clinical outcomes were recorded. Data analysis was performed using 1:1 propensity-score-matching and logistic regression modeling. A separate analysis of Hispanic and non-Hispanic patients was performed using Chi squared tests. Among 215,071 patients, racial distribution was 65.16% white, 19.13% black, 2.18% Asian, 0.74% American Indian/Alaskan Native, and 12.78% other. Flame injuries were the most common cause (35.2%), followed by scald burns (23.3%). All comparisons were made in reference to the white population. Black patients were more likely to die (OR: 1.28; 95%CI: 1.17-1.40), experience all (OR: 1.08; 95%CI: 1.03-1.14), cardiovascular (OR: 1.24; 95%CI: 1.08-1.43), or infectious (OR: 1.64; 95%CI: 1.40-1.91) complications, and less likely to experience airway complications (OR: 0.83; 95%CI: 0.74-0.94). American Indian/Alaskan Native patients were more likely to experience any complication (OR: 1.33; 95%CI: 1.05-1.70). All minority groups had increased length of hospital stay. Black, Asian, and other patients had longer length of ICU stay. Black patients had longer ventilator duration. Among 82,775 patients, 24,075 patients were identified as Hispanic and 58,700 as non-Hispanic. Statistically significant differences were noted between groups in age, TBSA, proportion of 2nd degree burn, and proportion of 3rd degree burn (p<0.01). These findings highlight the need for further work to determine the etiology of these disparities to improve burn care for all patients.

FAS(APO), DAMP, and AKT Phosphoproteins Expression Predict the Development of Nosocomial Infection After Pediatric Burn Injury.

Pediatric burn injuries are a leading cause of morbidity with infections being the most common acute complication. Thermal injuries elicit a heightened cytokine response while suppressing immune function; however, the mechanisms leading to this dysfunction are still unknown. Our aim was to identify extracellular proteins and circulating phosphoprotein expression in the plasma after burn injury to predict the development of nosocomial infection (NI). Plasma was collected within 72 hours after injury from sixty-four pediatric burn subjects; of these, eighteen went on to develop a NI. Extracellular damage associated molecular proteins (DAMPs), FAS(APO), and protein kinase b (AKT) signaling phosphoproteins were analyzed. Subjects who went on to develop a NI had elevated high mobility group box 1 (HMGB1), heat shock protein 90 (HSP90), and FAS expression than those who did not develop a NI after injury (NoNI). Concurrently, phosphorylated (p-) AKT and mammalian target of rapamycin (p-mTOR) were elevated in those subjects who went on to develop a NI. Quadratic discriminant analysis revealed distinct differential profiles between NI and NoNI burn subjects using HSP90, FAS, and p-mTOR. The area under the receiver-operator characteristic curves displayed significant ability to distinguish between these two burn subject cohorts. These findings provide insight into predicting the signaling proteins involved in the development of NI in pediatric burn patients. Further these proteins show promise as a diagnostic tool for pediatric burn patients at risk of developing infection while additional investigation may lead to potential therapeutics to prevent NI.

Impact of laser treatment on hypertrophic burn scars in pediatric burn patients.

Paediatric patients with hypertrophic burn scars benefit from laser treatment, but this treatment's effectiveness on burn wounds stratified by specific body region and prior burn wound therapy has not been fully evaluated. We performed a single center retrospective study of pediatric burn patients, treated with fractional CO2, with or without pulse dye, laser between 2018-2022. We identified 99 patients treated with 332 laser sessions. Median age at the time of burn injury was 4.0 years (IQR 1.7, 10.0) and 7.1 years (IQR 3.6, 12.2) at the time of first laser treatment. In the acute setting, 55.2 % were treated with dermal substrate followed by autografting, 29.6 % were treated with dermal substrate alone, and 9.1 % underwent autografting alone. Most body regions showed improvement in modified Vancouver Scar Scale (mVSS) score with laser treatment. mVSS scores improved significantly with treatment to the anterior trunk (-1.18, p = 0.01), arms (-1.14, p = 0.003), and legs (-1.17, p = 0.015). Averaging all body regions, the mVSS components of pigmentation (-0.34, p < 0.001) and vascularity (-0.47, p < 0.001), as well as total score (-0.81, p < 0.001) improved significantly. Knowing the variable effectiveness of laser treatment in pediatric burn scars is useful in counseling patients and families pre-treatment.

Association of initial assessment variables and mortality in severe pediatric traumatic brain injury.

Background: Predictive scales have been used to prognosticate long-term outcomes of traumatic brain injury (TBI), but gaps remain in predicting mortality using initial trauma resuscitation data. We sought to evaluate the association of clinical variables collected during the initial resuscitation of intubated pediatric severe patients with TBI with in-hospital mortality. Methods: Intubated pediatric trauma patients <18 years with severe TBI (Glasgow coma scale (GCS) score ≤8) from January 2011 to December 2020 were included. Associations between initial trauma resuscitation variables (temperature, pulse, mean arterial blood pressure, GCS score, hemoglobin, international normalized ratio (INR), platelet count, oxygen saturation, end tidal carbon dioxide, blood glucose and pupillary response) and mortality were evaluated with multivariable logistic regression. Results: Among 314 patients, median age was 5.5 years (interquartile range (IQR): 2.2-12.8), GCS score was 3 (IQR: 3-6), Head Abbreviated Injury Score (hAIS) was 4 (IQR: 3-5), and most had a severe (25-49) Injury Severity Score (ISS) (48.7%, 153/314). Overall mortality was 26.8%. GCS score, hAIS, ISS, INR, platelet count, and blood glucose were associated with in-hospital mortality (all p<0.05). As age and GCS score increased, the odds of mortality decreased. Each 1-point increase in GCS score was associated with a 35% decrease in odds of mortality. As hAIS, INR, and blood glucose increased, the odds of mortality increased. With each 1.0 unit increase in INR, the odds of mortality increased by 1427%. Conclusions: Pediatric patients with severe TBI are at substantial risk for in-hospital mortality. Studies are needed to examine whether earlier interventions targeting specific parameters of INR and blood glucose impact mortality.

Features of virtual reality impact effectiveness of VR pain alleviation therapeutics in pediatric burn patients: A randomized clinical trial.

Key features of virtual reality (VR) that impact the effectiveness of pain reduction remain unknown. We hypothesized that specific features of the VR experience significantly impact VR's effectiveness in reducing pain during pediatric burn dressing care. Our randomized controlled trial included children 6 to 17 years (inclusive) who were treated in the outpatient clinic of an American Burn Association-verified pediatric burn center. Participants were randomly assigned (1:1:1) to active VR (playing the VR), passive VR (immersed in the same VR environment without interactions), or standard-of-care. On a scale from 0 to 100, participants rated overall pain (primary outcome) and features of the VR experience (game realism, fun, and engagement). Path analysis assessed the interrelationships among these VR key features and their impact on self-reported pain scores. From December 2016 to January 2019, a total of 412 patients were screened for eligibility, and 90 were randomly assigned (31 in the active VR group, 30 in the passive VR group, and 29 in the standard-of-care group). The current study only included those in the VR groups. The difference in median scores of VR features was not statistically significant between the active (realism, 77.5 [IQR: 50-100]; fun, 100 [IQR: 81-100]; engagement, 90 [IQR: 70-100]) and passive (realism, 72 [IQR: 29-99]; fun, 93.5 [IQR: 68-100]; engagement, 95 [IQR: 50-100]) VR distraction types. VR engagement had a significant direct (-0.39) and total (-0.44) effect on self-reported pain score (p<0.05). Key VR features significantly impact its effectiveness in pain reduction. The path model suggested an analgesic mechanism beyond distraction. Differences in VR feature scores partly explain active VR's more significant analgesic effect than passive VR. Trial Registration: ClinicalTrials.gov Identifier: NCT04544631.

ALTERED PROFILES OF EXTRACELLULAR MITOCHONDRIAL DNA IN IMMUNOPARALYZED PEDIATRIC PATIENTS AFTER THERMAL INJURY.

ABSTRACT: Background: Thermal injury is a major cause of morbidity and mortality in the pediatric population worldwide with secondary infection being the most common acute complication. Suppression of innate and adaptive immune function is predictive of infection in pediatric burn patients, but little is known about the mechanisms causing these effects. Circulating mitochondrial DNA (mtDNA), which induces a proinflammatory signal, has been described in multiple disease states but has not been studied in pediatric burn injuries. This study examined the quantity of circulating mtDNA and mtDNA mutations in immunocompetent (IC) and immunoparalyzed (IP) pediatric burn patients. Methods: Circulating DNA was isolated from plasma of pediatric burn patients treated at Nationwide Children's Hospital Burn Center at early (1-3 days) and late (4-7 days) time points postinjury. These patients were categorized as IP or IC based on previously established immune function testing and secondary infection. Three mitochondrial genes, D loop, ND1, and ND4, were quantified by multiplexed qPCR to assess both mtDNA quantity and mutation load. Results: At the early time point, there were no differences in plasma mtDNA quantity; however, IC patients had a progressive increase in mtDNA over time when compared with IP patients (change in ND1 copy number over time 3,880 vs. 87 copies/day, P = 0.0004). Conversely, the IP group had an increase in mtDNA mutation burden over time. Conclusion: IC patients experienced a significant increase in circulating mtDNA quantity over time, demonstrating an association between increased mtDNA release and proinflammatory phenotype in the burn patients. IP patients had significant increases in mtDNA mutation load likely representative of degree of oxidative damage. Together, these data provide further insight into the inflammatory and immunological mechanisms after pediatric thermal injury.

A single institution case series of ReCell® use in treating pediatric burns.

BACKGROUND: Thermal injury has a significant impact on disability and morbidity in pediatric patients. Challenges in caring for pediatric burn patients include limited donor sites for large total body surface area (TBSA) burn as well as optimization of wound management for long term growth and cosmesis. ReCell® technology produces autologous skin cell suspensions from minimal donor split-thickness skin samples, allowing for expanded coverage using minimal donor skin. Most literature on outcomes reports on adult patients. OBJECTIVE: We present the largest to-date retrospective review of ReCell® technology use in pediatric patients at a single pediatric burn center. METHOD: Patients were treated at a quaternary care, free-standing, American Burn Association verified Pediatric Burn Center. A retrospective chart review was performed from September 2019 to March 2022, during which time twenty-one pediatric burn patients had been treated with ReCell® technology. Patient information was collected, including demographics, hospital course, burn wound characteristics, number of ReCell® applications, adjunct procedures, complications, healing time, Vancouver scar scale measurements, and follow-up. A descriptive analysis was performed, and medians were reported. RESULTS: Median TBSA burn on initial presentation was 31% (ranging 4%-86%). The majority of patients (95.2%) had placement of a dermal substrate prior to ReCell® application. Four patients did not receive split thickness skin grafting with their ReCell® treatment. The median time between date of burn injury and first ReCell® application was 18 days (ranging 5-43 days). The number of ReCell® applications ranged from 1-4 per patient. Median time until wound was classified as healed was 81 days (ranging 39-573 days). The median maximum Vancouver scar scale measurement per patient at time healed was 8, ranging from 3-14. Five patients who received skin grafts had graft loss and three of these patients had graft loss from areas with ReCell®. CONCLUSION: ReCell® technology provides an additional method for wound coverage, either on its own or in conjunction with split thickness skin grafting, and is safe and effective in pediatric patients.

Evaluating effects of burn injury characteristics on quality of life in pediatric burn patients and caregivers.

OBJECTIVES: The purpose of this study was to evaluate pediatric burn patients' and caregivers' quality of life (QoL), while identifying clinical characteristics correlated with psychological stress. METHODS: Pediatric burn patients at an ABA-verified institution from November 2019-January 2021 were included. Caregivers of patients 0-4 years completed the Infant's Dermatology QoL Index (IDQOL). Patients> 4-16 years completed the Children's Dermatology Life Quality Index (CDLQI). The Short Post-Traumatic Stress Disorder Rating Interview (SPRINT) measured caregivers' stress. Generalized linear mixed models evaluated associations between assessment scores and burn characteristics. RESULTS: Overall, 27.3% (39/143) of IDQOL and 53.1.% (41/96) of CDLQI scores indicated that patients' burns caused moderate to extremely large effects on QoL. In caregivers, 4.5% (7/159) scored> 14 on the SPRINT, warranting further PTSD evaluation. For the IDQOL, each additional 1% TBSA burn was associated with a 2.75-point increase (p = 0.05), and patients sustaining 2nd degree deep partial thickness burns scored an average of 3.3 points higher compared to 2nd degree superficial partial thickness burns (P < 0.01). CLDQI and SPRINT scores demonstrated a similar pattern. CONCLUSIONS: QoL is impacted in a substantial proportion of pediatric burn patients. Larger TBSA and increased burn depths cause significantly more psychological stress in children, and caregivers may require more extensive psychological evaluation.

DEMOGRAPHICS TO DEFINE PEDIATRIC BURN PATIENTS AT RISK OF ADVERSE OUTCOMES.

ABSTRACT: Background: There is currently no standard definition of a severe burn in the pediatric patient population to identify those at higher risk of infectious complications. Our aim was to correlate total burn surface area (TBSA), burn depth, and type of burn injury to nosocomial infection rates and systemic immune system responses to better define risk factors associated with adverse outcomes. Methods: A prospective observational study at a single-center, quaternary-care, American Burn Association-verified pediatric burn center was conducted from 2016 to 2021. Blood was collected within 72 h of injury from 103 pediatric patients. Whole blood was incubated with lipopolysaccharide or phytohemagglutinin stimulation reagent to measure innate and adaptive immune response, respectively. Flow cytometry was performed on whole blood samples to measure both innate and adaptive immune cells. Unstimulated plasma was also extracted, and IL-6 and IL-10 as well as soluble proteins B- and T-lymphocyte attenuator, CD27, and T-cell immunoglobulin mucin 3 were quantified. Results: There was a significant increased risk for nosocomial infection in pediatric patients with TBSA burns of ≥20%, full-thickness burn injuries ≥5%, or flame burn injuries. There was an overall decrease in both innate and adaptive immune function in patients with TBSA burns ≥20% or full-thickness burn injuries ≥5%. Both burn injury characteristics were also associated with a significant increase in unstimulated IL-6 and IL-10 and soluble immunoregulatory checkpoint proteins. We observed a significant decrease in soluble B- and T-lymphocyte attenuator for those with a flame injury, but there were no other differences between flame injury and scald/contact burns in terms of innate and adaptive immune function. Conclusion: Burns with ≥20% TBSA or ≥5% full thickness in pediatric patients are associated with systemic immune dysfunction and increased risk of nosocomial infections.

Extracorporeal Membrane Oxygenation in Pediatric Burn Patients Without Inhalation Injury: A Unique Population?

Prolonged mechanical ventilation (MV) before the initiation of extracorporeal membrane oxygenation (ECMO) is associated with decreased survival. Pediatric burn patients without inhalational injury are a unique population as they may be intubated for longer durations due to frequent interventions such as dressing changes and burn excisions. This study utilized the Extracorporeal Life Support Organization registry and evaluated patients 0 to 18 years old placed on ECMO and with a burn injury from January 2010 to December 2020. Inhalation injury was excluded. Descriptive statistics and bivariate analyses were performed. Multivariable logistic regression was used to assess the association between mortality and precannulation MV duration before ECMO cannulation, and odds ratios and predicted probabilities of mortality were estimated. Our cohort of 47 patients had a median age of 2.7 years old. Mortality occurred in 48.9% of the cohort. The overall median number of days on ECMO was 6.3 days, with no difference between survivors and non-survivors (6.8 days vs 6.3 days; P = .67). Survivors were ventilated for 4.1 days and non-survivors for 4.8 days before cannulation (P = .25). Regression modeling demonstrated that with each additional day on MV before ECMO cannulation, the odds of mortality increases by 12% (P = .03). Our study suggests that, similar to pediatric patients without thermal injury, increasing precannulation MV duration is associated with an increasing risk of mortality in pediatric burn patients without inhalational injury. Though the pediatric burn population is unique, evaluation of burn patients with respiratory failure for ECMO should be similar to the general population.

Association of Pre-procedural Anxiety With Procedure-Related Pain During Outpatient Pediatric Burn Care: A Pilot Study.

The relationship between preprocedural anxiety and pain is not clear but has the potential to change the way pediatric patients need to be cared for prior to burn procedures. Using results from our recent randomized clinical trial among outpatient burn patients (n = 90) aged 6-17 years, the objective of this subsequent analysis was to assess whether preprocedural anxiety was associated with self-reported and researcher-observed pain scores. Anxiety before the dressing change was assessed using an abbreviated State-Trait Anxiety Inventory for Children (range 6-21) and reported with 95% confidence intervals (CI). Self-reported pain was reported using a Visual Analog Scale (range 0-100) and observed pain was assessed using the Face, Legs, Activity, Cry, and Consolability-revised scale. Over half of patients (58.9%) reported mild anxiety (score < 12) and about 5% of patients reported severe anxiety (score > 16). Younger children (6-8 years) reported higher anxiety scores than older children (15-17 years), but the difference did not achieve statistical significance (mean = 12.7, 95% CI: 11.5 to 13.9, P = .09). Nonparametric spearman correlation indicated that anxiety score was significantly correlated with observed pain (P = .01) and self-reported overall pain neared statistical significance (P = .06). In the final logistic regression of reporting moderate-to-severe pain (pain score > 30), the association between anxiety scores and self-reported overall moderate-to-severe pain was statistically significant (P = .03) when adjusting for race, healing degree, and pain medication use within 6 hr prior to burn dressing care. This pilot study provides preliminary data showing that anxiety before outpatient pediatric burn dressing changes is significantly associated with self-reported overall moderate-to-severe pain.

Legal epidemiology of paediatric dog bite injuries.

BACKGROUND: Dog bite injuries cause over 100 000 paediatric emergency department visits annually. Our objective was to analyse associations between regional dog ownership laws and incidence of paediatric dog bites. METHODS: This observational study used an online search to locate local dog-related policies within Ohio cities. Data collected by Ohio Partners For Kids from 2011 through 2020 regarding claims for paediatric dog bite injuries were used to compare areas with and without located policies and the incidence of injury. RESULTS: Our cohort consisted of 6175 paediatric patients with dog bite injury encounters. A majority were white (79.1%), male (55.0%), 0-5 years old (39.2%) and did not require hospital admission (98.1%). Seventy-nine of 303 cities (26.1%) had city-specific policies related to dogs. Overall, the presence of dog-related policies was associated with lower incidence of dog bite injury claims (p=0.01). Specifically, metropolitan areas and the Central Ohio region had a significantly lower incidence when dog-related policies were present (324.85 per 100 000 children per year when present vs 398.56 when absent; p<0.05; 304.87 per 100 000 children per year when present vs 411.43 when absent; p<0.05). CONCLUSIONS: The presence of city-specific dog-related policies is associated with lower incidence of paediatric dog bite injury claims, suggesting that local policy impacts this important public health issue. There are limited dog-related policies addressing dog bite prevention, with inconsistencies in breadth and depth. Creating consistent, practical requirements among policies with vigorous enforcement could ameliorate public health concerns from paediatric dog bite injuries.

Early detection of soluble CD27, BTLA, and TIM-3 predicts the development of nosocomial infection in pediatric burn patients.

Thermal injury induces concurrent inflammatory and immune dysfunction, which is associated with adverse clinical outcomes. However, these effects in the pediatric population are less studied and there is no standard method to identify those at risk for developing infections. Our goal was to better understand immune dysfunction and identify soluble protein markers following pediatric thermal injury. Further we wanted to determine which early inflammatory, soluble, or immune function markers are most predictive of the development of nosocomial infections (NI) after burn injury. We performed a prospective observational study at a single American Burn Association-verified Pediatric Burn Center. A total of 94 pediatric burn subjects were enrolled and twenty-three of those subjects developed a NI with a median time to diagnosis of 8 days. Whole blood samples, collected within the first 72 hours after injury, were used to compare various markers of inflammation, immune function, and soluble proteins between those who recovered without developing an infection and those who developed a NI after burn injury. Within the first three days of burn injury, innate and adaptive immune function markers (ex vivo lipopolysaccharide-induced tumor necrosis factor alpha production capacity, and ex vivo phytohemagglutinin-induced interleukin-10 production capacity, respectively) were decreased for those subjects who developed a subsequent NI. Further analysis of soluble protein targets associated with these pathways displayed significant increases in soluble CD27, BTLA, and TIM-3 for those who developed a NI. Our findings indicate that suppression of both the innate and adaptive immune function occurs concurrently within the first 72 hours following pediatric thermal injury. At the same time, subjects who developed NI have increased soluble protein biomarkers. Soluble CD27, BTLA, and TIM-3 were highly predictive of the development of subsequent infectious complications. This study identifies early soluble protein makers that are predictive of infection in pediatric burn subjects. These findings should inform future immunomodulatory therapeutic studies.

Mobile phone virtual reality game for pediatric home burn dressing pain management: a randomized feasibility clinical trial.

BACKGROUND: Virtual reality (VR) gaming is considered a safe and effective alternative to standard pain alleviation in the hospital. This study addressed the potential effectiveness and feasibility of a VR game that was developed by our research team for repeated at-home burn dressing changes. METHODS: A randomized clinical trial was conducted among patients recruited from the outpatient burn clinic of a large American Burn Association-verified pediatric burn center between September 2019 and June 2021. We included English-speaking burn patients aged 5-17 years old requiring daily dressing changes for at least 1 week after first outpatient dressing change. One group played an interactive VR game during dressing changes, while the other utilized standard distraction techniques available in the home for up to a week. Both child and caretaker were asked to assess perceived pain on a numerical rating scale (NRS) of 0-10. For the VR group, patients were also asked to rate various aspects of the VR game on a NRS of 0-10 and caregivers were asked questions assessing ease of use. RESULTS: A total of 35 children were recruited for this study with 24 fully completing study measures. The majority of participants were male (n=19, 54.3%), White (n=29, 82.9%), and with second degree burns (n=32, 91.4%). Children and caregivers in the VR group reported less pain than the control group at the 4th dressing change. Participants in the VR group showed a clinically meaningful (≥30%) reduction in child-reported overall pain (33.3%) and caregiver-reported worst pain (31.6%) in comparison with subjects in the control group. Children's satisfaction with the VR remained at a high level across dressing changes over the 1-week period, with reported realism and engagement increasing over time. Over half of the children (54.5%) enjoyed playing the game and did not report any challenges nor any side effects. CONCLUSIONS: Subjects found the VR to be a useful distraction during home dressing changes and reported no challenges/side effects. VR should be considered as a nonpharmacologic companion for pain management during at-home burn dressing changes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04548635. Registered September 14, 2020-retrospectively registered.

Length of Stay Per Total Body Surface Area Burn: A Validation Study Using the National Burn Registry.

A length of stay (LOS) of one day per percent total body surface area (TBSA) burn has been generally accepted but not validated in current pediatric burn studies. The primary objective of this study is to validate previous Pediatric Injury Quality Improvement Collaboration (PIQIC) findings by using a national burn registry to evaluate LOS per TBSA burn relative to burn mechanism, sociodemographic characteristics, and clinical factors which influence this ratio. We evaluated patients 0-18 years old who sustained a burn injury and whose demographics were submitted to the National Burn Registry (NBR) dataset from July 2008 through June 2018. Mixed effects generalized additive regression models were performed to identify characteristics associated with the LOS per TBSA burn ratio. Among 51,561 pediatric burn patients, 45% were Non-Hispanic White, 58% were male, and median age was 3.0 years old (IQR: 1.0, 9.0). The most common burn mechanism was scald (55.9%). The median LOS per TBSA burn ratio across all cases was 0.9 (IQR: 0.4, 1.75). In adjusted models, scald burns had a mean predicted LOS per TBSA burn value of 1.2 while chemical burns had the highest ratio (4.8). Non-Hispanic White patients had lower LOS per TBSA burn ratios than all other races and ethnicities (p < .05). These data substantiate evidence on variance in LOS per TBSA burn relative to burn mechanism and race/ethnicity. Knowing these variations can guide expectations in hospital LOS for patients and families and help burn centers benchmark their clinical performance.

Interfacility helicopter transport to a tertiary pediatric trauma center.

BACKGROUND: Helicopter emergency medical services (HEMS) are intended to expedite care to definitive management. Studies are inconclusive in demonstrating appropriate use. We aimed to examine emergent interventions after interfacility helicopter transport (IHT) to our pediatric trauma center. METHODS: Trauma patients 0-18 years undergoing IHT or interfacility ground transport (IGT) to our institution from January 2011-December 2020 were studied. We evaluated the rate of IHT patients undergoing emergent (1 h), urgent (6 h), and semi urgent (48 h) operating room (OR) intervention compared to IGT as a measure of appropriate transport. RESULTS: Inclusion was met by 1003 IHT and 7829 IGT patients. OR intervention was required in 29.6% of IHT patients, emergent in 1.3%, urgent in 12.6%, and semi urgent in 10.6%. Overall, IHT patients had higher mean injury severity score (ISS; IHT:14.5; SD:11.0 vs. IGT:6.0; SD:5.0; p < 0.01) and lower GCS (IHT:12.0; SD:4.9 vs. IGT:14.8; SD:1.4; p < 0.01), though over triage (ISS ≤ 15) occurred in 67.9% of patients. CONCLUSION: More interfacility helicopter transport patients underwent emergent and urgent procedures compared to interfacility ground transport patients; however, emergent intervention was not required in 98.7% of interfacility helicopter transport patients and over two thirds had ISS ≤ 15, possibly suggesting overutilization of interfacility helicopter transport for pediatric trauma patients at our center. LEVEL OF EVIDENCE: Level III.

Measures of Adaptive Immune Function Predict the Risk of Nosocomial Infection in Pediatric Burn Patients.

Thermal injury results in changes in the inflammatory and innate immune response of pediatric patients. Plasma cytokines, cellular profiles, and reduction in innate immune function following burn injury have also been correlated to adverse outcomes (e.g., mortality and infectious complications). Changes in adaptive immune function following thermal injury are not as well characterized. Our goal was to better understand if adaptive immune dysfunction occurs early after pediatric thermal injury and is a risk factor for nosocomial infections (NIs). A prospective, longitudinal immune function observational study was performed at a single American Burn Association (ABA)-verified pediatric burn center. Eighty burn patients were enrolled with 20 developing NI, defined using Centers for Disease Control and Prevention (CDC) criteria. We collected whole blood samples from pediatric burn patients within the first 72 hours from injury and between days 4 and 7, where applicable to analyze adaptive immune function. We compared immune function between burn patients who went on to develop NI and those that did not. Within the first 72 hours of injury, burn patients who developed NI had significantly lower absolute CD4+ lymphocyte counts and whole blood ex vivo phytohemagglutinin (PHA)-induced interferon gamma (IFNγ) and interleukin-10 (IL-10) production capacity compared to those that did not develop infection. Further analysis using receiver operating characteristic curve revealed that PHA-induced IL-10 production capacity had the highest area under the curve. Our data demonstrate that early adaptive immune suppression occurs following pediatric thermal injury and PHA-induced IL-10 production capacity appears to be a predictor for the development of NI.

The role of macrophages in thermal injury.

Macrophages, first discovered for their phagocytic ability, are a complicated and heterogeneous cell type. The unique properties of macrophages allow them to perform a vast array of functions, including phagocytosis, cytokine production, antigen presentation, and wound healing. Some macrophage populations are derived from monocytes and are induced into specific phenotypes by the local tissue microenvironment, while other macrophages form during early embryonic development. The exposure of the host to local pathogens and/or traumatic injury alters the tissue microenvironment and, in turn, influences changes in macrophage phenotype and function. Perhaps the most significant change in the local tissue microenvironment and subsequent macrophage phenotype occurs after thermal injury, which causes localized tissue damage and a massive systemic inflammatory response. However, few studies have explored the influence of burn injury on the host macrophages and macrophage function in burn wounds. Furthermore, the literature is scant regarding the impact macrophage function has on outcomes in thermal injury. This review will focus on the current knowledge of macrophage function in burn wounds and the phenotypic changes in macrophages during thermal injury while identifying knowledge gaps.

Implementation of a Level 1 Neuro Trauma Activation at a Tertiary Pediatric Trauma Center.

INTRODUCTION: Timely management improves outcomes in patients with traumatic brain injury (TBI), especially those requiring operative intervention. We implemented a "Level 1 Neuro" (L1N) trauma activation for severe TBI, aiming to decrease times to intervention. METHODS: We evaluated whether an L1N activation was associated with shorter times to operating room (OR) incision and pediatric intensive care unit (PICU) admission using multivariable regression models. Trauma patients with severe TBI undergoing operative intervention or PICU admission from January 2008-October 2020 met inclusion. The L1N cohort included patients meeting our institution's L1N criteria. The L1 and L2 cohorts included head injury patients with hAIS ≥3 and an L1 or L2 activation, respectively. RESULTS: Median hAIS, GCS, Rotterdam CT score, and ISS were 4.5 (4-5), 8 (3-15), 2 (1-3), and 17 (11-26), respectively. We demonstrate clinically shorter times to OR incision among L1N traumas (93.3 min) compared to L1 (106.7 min; P = 0.73) and L2 cohorts (133.5 min; P = 0.03). We also demonstrate clinically shorter times to anesthesia among L1N traumas (51.9 min) compared to L1 (70.1 min; P = 0.13) and L2 cohorts (101.3 min; P < 0.01). Median GCS, ISS and hAIS in the PICU patients were 10 (IQR:3-15), 17 (11-26), and 4 (3-4), respectively. We demonstrate clinically shorter times to PICU among L1N traumas (82.1 min) and the L2 cohort (154.7 min; P < 0.01). CONCLUSIONS: An L1N activation is associated with shorter times to anesthesia and OR management. Enhancing communication with standardized neurotrauma activation has the potential to improve timeliness of care in severe pediatric TBI.

Defining Benchmarks in Pediatric Burn Care: Inception of the Pediatric Injury Quality Improvement Collaborative.

Pediatric burn care is highly variable nationwide. Standardized quality and performance benchmarks are needed for guiding performance improvement within pediatric burn centers. A network of pediatric burn centers was established to develop and evaluate pediatric-specific best practices. A multi-disciplinary team including pediatric surgeons, nurses, advanced practice providers, pediatric intensivists, rehabilitation staff, and child psychologists from five pediatric burn centers established a collaborative to share and compare performance improvement data, evaluate outcomes, and exchange best care practices. In December 2016, the Pediatric Injury Quality Improvement Collaborative (PIQIC) was established. PIQIC members chose quality improvement indicators, drafted and approved a memorandum of understanding (MOU), data use agreement (DUA) and charter, formalized the multidisciplinary membership, and established a steering committee. Since inception, PIQIC has conducted monthly teleconferences and biannual in-person or virtual group meetings. A centralized data repository has been established where data is collated and analyzed for benchmarking in a blinded fashion. PIQIC has shown the feasibility of multi-institutional data collection, implementation of performance improvement metrics, publication of research, and enhancement of aggregate and institution-specific pediatric burn care.