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Amniotic Fluid Injections in Chronic Non-Healing Wounds in Pediatric Patients: A Case Series
Amniotic tissues are used to support wound healing in a variety of fields and wound types including chronic stasis ulcers, lower extremity wounds in diabetic patients, poorly healing injuries associated with burns, and surgical wounds associated with intestinal fistulas. To date, the use of amniotic fluid (AF) alone has not been described in the literature. The properties of AF alone would suggest the potential for regenerative and accelerated healing. This descriptive, retrospective review evaluates the effects of AF injected into chronic, poorly healing burn wounds.
Outbreak of Carbapenem-Polymyxin-Quat-Resistant Acinetobacter Baumannii Associated with Mafenide Acetate shortages: An Interdisciplinary Approach to Eradication
In the wave of Hurricane Maria, many US hospitals experienced massive drug shortages requiring substitution with alternative therapies. Our regional center experienced an increased incidence of Carbapenem-Polymyxin-Quat-Resistant Acinetobacter baumannii (CPQRA) infections, compared to a previous year of no infections. Here we describe a successful interdisciplinary approach to its eradication.
Venous Thromboembolism Prophylaxis in Burn Patients: Analyzing the Effectiveness of a Standardized Protocol
Burn patients have a high risk of developing venous thromboembolism (VTE) due to extensive immobilization, surgical interventions, endothelial injury, and the presence of polytrauma. Studies have shown VTE rates ranging from 0.25% to 23.3% in this patient population. Although burn patients have a greater risk for VTE compared to other hospitalized patients, there are no standardized guidelines on how to approach VTE prophylaxis in the burn population. In March 2018, the Burn Intensive Care Unit (BICU) implemented a new VTE prophylaxis protocol that stratified patients based on risk factors for VTE. Patients were started on enoxaparin 30mg every 12 hours or 40mg every 12 hours depending on body mass index (BMI). The purpose of this study was to examine compliance with the new protocol and overall rates of VTE in the burn population.
One Year Follow up Results of the DETECT Enzymatic Debridement Multicenter RCT
Bromelain Based Debridement (BBD) of deep thermal burns has been approved for use in Europe, Argentina, Russia, South Korea, Peru, and Israel, and is an investigational product in the United States. Topline results of acute stage endpoints of the DETECT Phase 3 multicenter RCT have been reported previously. The aim of this abstract is to present the 12-month follow-up of predefined endpoints of scar quality, function and quality of life (QoL).
Frailty Assessment in the Burn Population: A Single Center Retrospective Review
Burn morbidity and mortality increases with advancing age. Frailty is characterized by reduced homeostatic reserves and is associated with an increased biological age compared to chronological age. Our primary aim was to determine whether frailty as assessed on admission would be predictive of outcomes in the burn population.
Smoking on Home Oxygen and Burn Related Injuries. A Single Center Experience
Oxygen therapy is a mainstream treatment for many cardiopulmonary disease processes in the United States with COPD being most common. Despite various warnings against smoking on oxygen therapy, some patients continue to smoke on oxygen and sustain burn-related injuries. These patients are frequently intubated due to concern for inhalation injury. We aim to characterize the injury patterns, morbidities, and mortalities associated with burns sustained while on oxygen therapy at home. We hypothesize that the prevalence of these injuries is underrecognized.
Safety and feasibility of using acellular sterile filtered amniotic fluid as a treatment for patients with COVID-19: protocol for a randomised, double-blinded, placebo-controlled clinical trial
Human amniotic fluid (hAF) has been shown to reduce inflammation in multiple experimental models. hAF has previously been approved by the US Food and Drug Administration (FDA) as a human cellular and tissue product for tissue injury for human administration, and used safely in thousands of patients as a therapeutic treatment for diverse conditions. Given the profound inflammatory response observed in patients with COVID-19, and the successful completion of 10-patient pilot study of intravenous hAF, we present a trial design for a larger clinical trial of intravenous hAF for the treatment of COVID-19.
A pilot trial of human amniotic fluid for the treatment of COVID-19
Vertical transmission from SARS CoV-2-infected women is uncommon and coronavirus has not been detected in amniotic fluid. Human amniotic products have a broad immune-mediating profile. Observing that many COVID-19 patients have a profound inflammatory response to the virus, we sought to determine the influence of human amniotic fluid (hAF) on hospitalized patients with COVID-19.
Amnion membrane allografts in a critically ill infant with Netherton syndrome-like phenotype
Netherton syndrome (NS) is a triad of nonbullous congenital ichthyosiform erythroderma, typical hair dysplasia, and severe atopic features. The incidence is 1 in 50,000 births, with 18% of all congenital erythrodermas attributed to NS. The skin is noted to be abnormal at birth or within the first month of life. Complications include thermoregulatory problems, electrolyte imbalances, hypernatremic dehydration, recurrent or severe infections, and failure to thrive. Skin hygiene represents a challenge in critically ill and unstable patients. This report describes a novel approach to skin management in NS.
Amniotic membrane dressings: an effective therapy for SSc-related wounds
SIR, SSc is an autoimmune disease reffered to rheumatologists with profound morbidity and mortality. Ninety per cent of patients with SSc will experience RP; the sequellae include variable levels of ischaemia-induced ulceration leading to significant tissue loss. SSc-related digital ulcers (DUs), which occur in ∼50% of patients and reoccur in up to 70% of these patients, are a devastating complication of this disease that influence all aspects of self-care. Lower extremity and elbow ulcerations are also a major source of morbidity and have limited treatment options.
Accepted therapies to heal and/or prevent DUs are often secondarily assessed in RP clinical trials. Consequently, the effectiveness of wound therapy for DUs is often difficult to assess and inconclusive, limited by small sample sizes, lack of randomization, blinding and inconsistent measurements. It is recognized that SSc disease features influence the natural history of DU formation, yet the impact of local DU wound care is unknown. The goal of this study was to evaluate our standard wound care practice using regenerative tissue applied directly to digital and extremity ulceration with digital photography to assess time to healing.
Identification of substance use disorders in burn patients using simple diagnostic screening tools (AUDIT/DAST-10)
Substance use is disproportionately high in burn patients and associated with adverse outcomes. Screening methods for substance use disorders may help predict or avoid adverse outcomes.
The University of Utah Burn Center records self-reported Alcohol Use Disorders Identification Tests (AUDIT) and Drug Abuse Screening Tests (DAST-10) for all adult burn admissions. This study assessed for association between AUDIT/DAST-10 scores and burn patient outcomes.
Review of local wound management for scleroderma-associated digital ulcers
Digital ulcers (DU) are a common clinical problem in systemic sclerosis (SSc); however, there is no standardization of local wound care protocols for management of these lesions. There is a well-recognized need to develop and standardize non-pharmacological management of DU in patients with SSc, and to adopt these protocols in future clinical trials that focus on DU healing. The purpose of this review is to outline the types of DU that occur in SSc, and provide an update on the principles of wound management for these lesions based on the current literature and expert opinion.
Evaluation of High-Dose Ascorbic Acid in Thermal Injury
Burns >20% total body surface area (TBSA) are associated with hypovolemic shock and release of inflammatory mediators, which can lead to production of reactive oxygen species that propagate shock by increased vascular permeability. Aggressive fluid resuscitation is paramount to minimize end organ damage in severe burns. Fluid resuscitation is initiated based on burn size with Lactated Ringer's solution (LR) and titrated to a goal urine output (UOP)of 30-50 mL/hr. At the University of Utah Burn Center, albumin is added at a ratio of 1/3 albumin to 2/3 LR if UOP goals are not met. High-dose ascorbic acid (AA) may also be added if patients are failing resuscitation. Ascorbic acid is a free radical scavenger that may reduce vascular permeability by inactivating reactive oxygen species. Despite reported benefits of AA during resuscitation, concerns for osmotic diuresis and risk for renal injury have limited widespread use in burn centers.
Cold-induced injury: Frostbite
This chapter provides an overview of the history and pathophysiology of frostbite, as well as current clinical recommendations for treatment of frostbite. Frostbite has a dual pathophysiologic etiology due to freezing of soft tissues and microvascular thrombosis. The inflammatory features of early frostbite mimic those of burn injury, particularly the chemokine milieu of blisters. Thrombolytic therapy has shown promise for digital salvage when patients present early following frostbite, but effective therapies for delayed presentations of frostbite remain elusive at this time. Further study is needed of modalities including thrombolytics, prostacyclin analogs, and hyperbaric oxygen.
Skewed Groups, Implicit Sex Bias, and Trainee Evaluations
The recent publication by Fassiotto et al., reinforces yet another challenge for female academic surgeons and those in other “low representation” specialties: that of bias in evaluations by trainees. In this new study, the “threshold” value for female representation in specialties was based upon American Association of Medical Colleges (AAMC) demographic data and the mean percentage of female faculty across all specialties included in the AAMC sample. The cut point of 32.6% has an interesting congruency with male-dominant groups moving from skewed to tilted when approximately 35% of members of a group are women. Low representation specialties remain skewed, and the impact of those skewed groups has a profound impact on the professional experiences of female faculty in those specialties. The continued skewing within surgical specialties contributes, as noted by the authors, to implicit bias based upon sex stereotype nonconformance.
Fixed-Dose Enoxaparin Prophylaxis Is Inadequate for the Majority of Surgical Patients and Inadequate Dosing Predicts Postoperative Venous Thromboembolism
“Breakthrough” venous thromboembolism (VTE) events, or events that occur despite receipt of chemical prophylaxis, remain an enigma for surgeons. The goal of this study was to evaluate the degree of anticoagulation achieved with standard doses of enoxaparin prophylaxis using anti-factor Xa (aFXa) levels and to examine the relationship between aFXa and downstream 90-day VTE events.
Professional Use of Social Media Among Surgeons: Results of a Multi-Institutional Study
Among surgeons, professional use of social media (SM) is varied, and attitudes are ambiguous. We sought to characterize surgeons' professional use and perceptions of SM.
Standardized Handoffs in the Intensive Care Unit: Hope or Hype for Improving Critical Care?
Transitions in patient care do not occur without negative consequences. We have known for more than 20 years that a cross-covering physician dramatically increases the risk of preventable adverse events. The 2003 implementation of duty hour restrictions increased the number of handoffs required for care of inpatients; these changes also led many to question whether duty hour restrictions were a benefit or detriment to patient safety, with both medicine and surgery residents indicating that patient harm commonly resulted from handoffs. No place is there more potential for patient harm resulting from handoffs than the intensive care unit (ICU), owing to patients’ severity of illness and the resulting complexity of this patient population.
The Effects of Storage Age of Blood in Massively Transfused Burn Patients: A Secondary Analysis of the Randomized Transfusion Requirement in Burn Care Evaluation Study
Major trials examining storage age of blood transfused to critically ill patients administered relatively few blood transfusions. We sought to determine if the storage age of blood affects outcomes when very large amounts of blood are transfused.
Increased mortality in women: sex differences in burn outcomes
There is increasing evidence that sex differences may influence responses after thermal injury and affect clinical outcomes. The objective of this study was to evaluate the relationships between sex, thermal injury, body size, and inpatient mortality in burn patients.
Early Diagnosis and Prevention of Ischemic Enterocolitis in Massive Burns
To summarize the most salient literature regarding the pathogenesis, diagnosis, and prevention of ischemic enterocolitis (IE) in thermal injury. IE is a poorly characterized gastrointestinal complication associated with large burns. This entity occurs irrespective of abdominal trauma. The diagnostic challenges, paucity of treatment options and related complications make IE particularly lethal. Herein we present a case of profound IE in a 40-year-old male who sustained 80% total body surface area (TBSA) burns. We provide an overview of our current understanding of IE, discuss early diagnostic strategies, and review possible treatment options. Although there are several promising biomarkers of early IE and potential treatment strategies, prospective studies are lacking. IE secondary to massive thermal injury is a lethal complication of severely burned patients. Early recognition and evidenced-based treatment strategies are paramount to successful management of patients with IE. Additional research and prospective trials are warranted given this devastating complication of massive burns.
A Brave New World of Research Ethics
The findings from the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial by Bilimoria et al were released in February 2016 to great fanfare and substantial controversy around the issues reviewed by Minami et al. Bilimoria et al make a strong case that this was a necessary trial with significant social benefit, both for the safety of surgical trainees and the safety of surgical patients. They also acknowledge the complexity of the ethical issues around the FIRST Trial and the fact that different perspectives can easily result in different conclusions regarding the need for additional scrutiny in terms of human subjects protection. A critical issue that is understated by Bilimoria et al is that research into quality and safety requires reframing ethical norms at a systemic level; the traditional model of human subjects protection is not equipped to provide ethical oversight at this level.
Expanding Burn Care Knowledge in a Rural Region Through Project Extension for Community Healthcare Outcomes
Project ECHO (Extension for Community Healthcare Outcomes) is a dynamic health care delivery platform for rural and underserved populations pioneered at the University of New Mexico in 2004 by Sanjeev Arora, MD, a hepatologist. He observed that thousands of individuals with hepatitis C (HCV) across rural New Mexico were not receiving treatment owing to a shortage of HCV specialists in the state and long waits at the few facilities that did treat HCV. These observations inspired the creation of Project ECHO, with the goal of providing primary care clinicians with the specialized medical knowledge needed to effectively address, treat, and cure individuals with HCV. The HCV ECHO experience was replicated in Utah in 2011 by Terry Box, MD. The Senate recently passed the Expanding Capacity for Health Outcomes Act, which promotes ECHO as a model for rural health care.
Venous Thromboembolism in Patients with Thermal Injury: A Review of Risk Assessment Tools and Current Knowledge on the Effectiveness and Risks of Mechanical and Chemical Prophylaxis
Virchow’s triad of stasis, hypercoagulability, and intimal damage describes the broad categories of factors that contribute to thrombotic risk. Patients with thermal injury seem to have the ideal physiologic predisposition to the Virchow’s triad, and thus should be at high risk for postinjury venous thromboembolism events. Endothelial dysfunction via disruption of junctional proteins and stress fibers results in altered paracellular flow of solutes or capillary leak, manifested by edema and altered fluid balance. Alterations in coagulation, including deficiency of natural anticoagulant antithrombin and altered fibrinogen, predispose toward a prothrombotic state. In addition, burn dressings and use of split-thickness skin grafts make immobilization and resulting venous stasis inevitable in the current treatment paradigm of major cutaneous burns.
Virchow’s triad notwithstanding, venous thromboembolism (VTE) is a rare event (0.6%) in the burn population. However, more than 10-fold variability in postinjury VTE risk exists among the overall population with thermal injury. As a rare event, VTE in thermally injured patients cannot rigorously be studied using case series or small, single-center studies. This article reviews the current knowledge of VTE in the thermally injured populations, with a focus on (1) the utility of large-database approaches for VTE research, and (2) an overview of VTE risk stratification and prevention.
Strategies for Identifying and Closing the Gender Salary Gap in Surgery
In this article, we discuss the issues that contribute to gender salary inequity and make some recommendations for best practices to address this disparity.
Opioid Use in Trauma: Combating the "Opidemic" Through Thoughtful Prescribing Practices
The use of opioids for moderate to severe pain following acute traumatic injury may be appropriate based on individual pain scores. But are other practices, including quantities prescribed and plans for follow-up, appropriate as well? Based on the data available to Chaudhary et al,1 we do not have clear answers to these questions, which would allow better understanding of appropriate opioid prescribing practices for trauma patients.
Transfusion Requirement in Burn Care Evaluation (TRIBE): A Multicenter Randomized Prospective Trial of Blood Transfusion in Major Burn Injury
Our objective was to compare outcomes of a restrictive to a liberal red cell transfusion strategy in 20% or more total body surface area (TBSA) burn patients. We hypothesized that the restrictive group would have less blood stream infection (BSI), organ dysfunction, and mortality.
An Examination of a Yoga Intervention With Pediatric Burn Survivors
Burn injuries have a major influence on the survivors' physical and psychological functioning. In pediatric burns, the consequences persist long after the injury. The objective of this study is to evaluate an existing yoga kids program to gain better understanding of the physical and psychosocial effects of a yoga practice among children with burn injuries. Thirty campers participated in a series of four (1 hour) yoga sessions during the summer of 2014. Nationally trained Instructors had taught children's yoga in the Southwestern United States for at least 10 years. A Yoga Evaluation Questionnaire, designed for children, was used to evaluate perceptions of somatic and cognitive anxiety before and after each Yoga session. Camper's age ranged from 6 to 12 years old with burn severities ranging from 5 to 75%. A dependent samples t-test was used to test for differences between composite pre- and postintervention scores for both somatic and cognitive anxiety. Significant effects emerged for somatic anxiety t(29) = -4.24, P < .001, d = 0.77, and cognitive anxiety t(29) = -4.188, P < .001, d = 0.76. For both cognitive and somatic anxiety, the postintervention composite mean scores were significantly higher, indicating a decrease in somatic and cognitive anxiety. This study suggests that participation in a Yoga program may lower perceptions of cognitive and somatic anxiety in pediatric burn survivors. Further, Yoga is one technique that may compliment the short- and long-term treatment of burn injuries.
Contacts and Helpful Links
Anna Darelli-Anderson, MEd, BA, C-TAGME
University of Utah
Department of Surgery
30 N. Mario Capecchi Dr. 4N153
Salt Lake City, UT 84112
801-581-6345
anna.darelli-anderson@utah.edu
Tonya Pickron, MEd, BA
University of Utah
Department of Surgery
30 N. Mario Capecchi Dr. 4N217.01
Salt Lake City, UT 84112
tonya.pickron@hsc.utah.edu