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In 2019, we implemented a pill-based, opioid-minimizing pain protocol and protocolized moderate sedation for dressing changes in order to decrease opioid exposure in burn patients. We hypothesized that these interventions would reduce inpatient opioid exposure without increasing acute pain scores. Two groups of consecutive patients admitted to the burn service were compared: Pre-group (from January 1, 2018 to July 31, 2019) and Post-group (from January 1, 2020 to June 30, 2020) from before and after the implementation of the protocols (from August 1, 2019 to December 31, 2019). We abstracted patient demographics and burn injury characteristics from the burn registry. We obtained opioid exposure and pain scale scores from the electronic medical record. The primary outcome was total morphine milligram equivalents (MMEs). Secondary outcomes included MMEs/day, pain domain-specific MMEs, and pain scores. Pain was estimated by creating a normalized pain score (range 0–1), which incorporated three different pain scales (Numeric Rating Scale, Behavioral Pain Scale, and Behavioral Pain Assessment Scale). Groups were compared using Wilcoxon rank-sum and chi-square tests. Treatment effects were estimated using Bayesian generalized linear models. There were no differences in demographics or burn characteristics between the Pre-group (n = 495) and Post-group (n = 174). The Post-group had significantly lower total MMEs (Post-group 110 MMEs [32, 325] vs Pre-group 230 [60, 840], P < .001), MMEs/day (Post-group 33 MMEs/day [15, 54] vs Pre-group 52 [27, 80], P < .001), and domain-specific total MMEs. No difference in average normalized pain scores was seen. Implementation of opioid-minimizing protocols for acute burn pain was associated with a significant reduction in inpatient opioid exposure without an increase in pain scores.

Introduction Concomitant traumatic injury in the burn patient complicates care coordination and increases morbidity and mortality. The incidence of concomitant injury, however, is uncommon and reported to range from 5–7%. In May 2020, our level 1 trauma center began seeing 40% more patients per month that the 12 months prior. We sought to determine the incidence of concomitant injury in burn patients during this time of increased trauma volume and to examine the associated traumatic injuries in this group. Methods The burn registry at a single ABA-verified burn center was examined from 5/20–9/20. Patients with concomitant burn and traumatic injury were examined with respect to: %TBSA burn, mechanism of injury, operative interventions, associated traumatic injuries, and length of hospital stay. Continuous data was presented as mean (standard deviation). Results Eighty-nine burn patients were admitted during this period, of whom 24 (26.9%) had concomitant traumatic injuries. The cohort was young and mostly male; the mean TBSA was 16% () (Table 1). The most common mechanism of injury was motor vehicle collision (12 or 50%), followed by fall after high voltage electrical injury (6 or 25%) and motorcycle collisions (5 or 21%). The most common associated injuries were: pulmonary contusions 29.1% (7/24); long bone fractures 25% (6/24); pelvic/acetabular fractures 20.8% (5/24); femur fractures 16.6% (4/24); and solid organ injury: 16.6% (4/24). Twenty patients (83.3%) required burn or trauma operative intervention during hospital stay. Of the 20 patients who required operative intervention, 85% underwent burn surgery and 55% underwent trauma surgery (solid organ or orthopedic). Forty percent of these patients required operation for both burn and traumatic injury. In looking specifically at the electric injury group, all six patients required operative intervention for burn injuries, and four required extremity fasciotomy. Patients with electrical injury had a significantly longer hospital stay relative to their TBSA (p< 0.04). Conclusions Concomitant trauma and burn injuries are infrequent yet present a major clinical challenge. Our recent increase in overall trauma volume was paralleled by an increase in patients with concomitant burn injuries. The associated traumatic injuries require a multi-disciplinary approach to minimize morbidity and restore function.

Introduction Traditionally, opioids have been the mainstay of treatment for background, breakthrough, procedural, and postoperative pain after burns. However, in addition to an impetus to reduce provider-driven opioid exposure, there is increasing evidence that opioids can worsen acute pain through induction of hyperalgesia. In 2019, we implemented a pill-based, opioid-minimizing pain protocol and protocolized moderate sedation for dressing changes. We hypothesized that these protocols would reduce inpatient opioid exposure without increasing acute pain scores. Methods Two groups of consecutive patients admitted to the burn service were compared: Pre (01/2018 to 07/2019) and Post (01/2020 to 06/2020) implementation of the protocols (08/2019 to 12/2019). Patient demographics, burn characteristics, and lengths of stay were abstracted from the burn registry. Opioid exposure and pain scale scores were obtained from the electronic medical record. The primary outcome was total morphine milligram equivalents (MME). Secondary outcomes included MME/day, pain domain specific MME, pain scores, and lengths of stay. Pain was estimated by creating a normalized pain score (range 0–1) from three different pain scales (Numeric Rating Scale, Behavioral Pain Scale, and Behavioral Pain Assessment Scale). Groups were compared using Wilcoxon Rank Sum and Chi Square. Treatment effect was estimated using Bayesian generalized linear models. Results There were no differences in demographics or burn characteristics between the Pre (n=495) and Post groups (n=174), including TBSA burn (Pre 4% [2, 10] versus Post 5% [2, 10], p=0.898). The Post group had significantly lower total MME (IRR 0.72, 95% CrI 0.57–0.93, posterior probability 99%), MME/day (IRR 0.76, 95% CrI 0.65–0.90, posterior probability 99%), and domain-specific total MME (Table). No difference in average normalized pain scores was seen. The Pre group were hospitalized longer than the Post group (5 days [2, 14] versus 4 days [1, 9], p=0.012). Conclusions Implementation of opioid-minimizing protocols for acute burn pain were associated with a significant reduction in inpatient opioid exposure without increased pain scores. More information is needed to understand the association with reduced hospital days.

Introduction Burn injury is uniquely characterized by the initial traumatic event in addition to the psychiatric component associated with physical change and recovery. Recent work has highlighted the importance of pre-existing psychiatric illness on both recovery and final outcomes in burn patients (Tarrier et al 2005, Hudson et al 2017, Wisely et al 2009). We examined the prevalence and association of psychiatric illness in our ABA verified burn unit. Knowledge of this information is critical in allocation of limited resources aimed toward addressing both the physical and mental aspect of burn injury. Methods The burn registry at a single verified burn center was examined from July 2017-July 2018. All consecutive burn patients with psychiatric illness who were admitted were included. Psychiatric illness was broken down into: depression, anxiety, bipolar disorder, schizophrenia and delirium. Need for psychiatric consultation, %TBSA, length of hospital stay, and operative intervention was also examined. Results 416 patients were admitted during the study period—44 pts (10.5%) had a psychiatric diagnosis on admission. Seventy-five percent of pts were male. The average TBSA burned was 15.3%. Seventy-five percent of patients required psychiatric consultation, and 57% required operative intervention (Table 1). The most common psychiatric condition was anxiety (50%), followed by depression (36%), bipolar disorder (27%), schizophrenia (23%), and delirium (18%). Forty-eight percent of patients had multiple (>1) psychiatric conditions. Female patients had a significant less TBSA burn (5.8%) vs. male (18.2%), P=.001, as well as a shorter LOS (12.1 dys vs. 31.5 dys) p=.004. Conclusions The association between burn injury and pre-existing psychiatric illness is well known (Hudson et al 2017, Wisely et al 2009). We found that over 10% of pts admitted to our burn unit had a psychiatric diagnosis, and a large number of these required further inpatient psychiatry consultation. More than half of patients required operative intervention indicating that severity of burn injury was high, with optimization of pre-existing conditions especially important. Additionally, psychiatric illness did not occur in isolation--48% of pts had >1 psychiatric diagnosis —a finding which has implications for resource allocation for mental health/ dedicated psychiatrist for burn patients. Applicability of Research to Practice Implications for resource allocations for dedicated burn psychiatrist/ resources for mental health.

Highlights • Pancreatic rhabdomyosarcoma is an extremely rare disease. • Pre-operative diagnosis is challenging due to unspecific presentation. • Surgical resection followed by chemotherapy and radiotherapy are the only possible treatments. • Long term prognosis is very poor., Introduction Rhabdomyosarcoma (RMS) is a primary malignancy that arises from the embryonic mesenchyme with the potential to differentiate into skeletal muscle. RMS of the biliary tree is extremely rare. We report a case of an undifferentiated pleomorphic RMS involving the liver and pancreas. Presentation of case A 62 year old Caucasian woman with rapidly growing abdominal mass and a history of endometrial adenocarcinoma underwent laparotomy due to compression symptoms and concerns of malignancy. A large mass arising from the pancreas and extending into the liver was identified and resected with a distal pancreatectomy associated with a left lateral liver segmentectomy. A diagnosis of pleomorphic RMS was made from the pathology specimen. Chemotherapy and radiotherapy were also performed. Unfortunately the patient died 2 years following treatment due to recurrence of the disease. Discussion P-RMS in the biliary tree is extremely rare (0.5%) and mostly seen in infants and children. Preoperative diagnosis is challenging since the symptoms are unspecific. Preoperative imaging rarely contributes to the final diagnosis. The only possible treatment for adult RMS is surgical resection of the tumor followed by chemotherapy and radiotherapy. Long-term prognosis of P-RMS reported (predominantly of limbs) is poor. To our knowledge, no previous cases of RMS originating from the pancreas have been reported. Conclusion However RMS is an extremely rare tumor in adults, it should be included in the differential diagnosis of patients with atypical pancreatic and liver lesions.

Background Glucocorticoids (GC's) play an integral role in treatment strategies designed to combat various forms of hematological malignancies. GCs also are powerful inhibitors of the immune system, through regulation of appropriate cytokines and by causing apoptosis of immature thymocytes. By activating the glucocorticoid receptor (GR), GCs evoke apoptosis through transcriptional regulation of a complex, interactive gene network over a period of time preceding activation of the apoptotic enzymes. In this study we used microarray technology to determine whether several disparate types of hematologic cells, all sensitive to GC-evoked apoptosis, would identify a common set of regulated genes. We compared gene expression signatures after treatment with two potent synthetic GCs, dexamethasone (Dex) and cortivazol (CVZ) using a panel of hematologic cells. Pediatric CD4+/CD8+ T-cell leukemia was represented by 3 CEM clones: two sensitive, CEM-C7–14 and CEM-C1–6, and one resistant, CEM-C1–15, to Dex. CEM-C1–15 was also tested when rendered GC-sensitive by several treatments. GC-sensitive pediatric B-cell leukemia was represented by the SUP-B15 line and adult B-cell leukemia by RS4;11 cells. Kasumi-1 cells gave an example of the rare Dex-sensitive acute myeloblastic leukemia (AML). To test the generality of the correlations in malignant cell gene sets, we compared with GC effects on mouse non-transformed thymocytes. Results We identified a set of genes regulated by GCs in all GC-sensitive malignant cells. A portion of these were also regulated in the thymocytes. Because we knew that the highly Dex-resistant CEM-C1–15 cells could be killed by CVZ, we tested these cells with the latter steroid and again found that many of the same genes were now regulated as in the inherently GC-sensitive cells. The same result was obtained when we converted the Dex-resistant clone to Dex-sensitive by treatment with forskolin (FSK), to activate the adenyl cyclase/protein kinase A pathway (PKA). Conclusion Our results have identified small sets of genes that correlate with GC-sensitivity in cells from several hematologic malignancies. Some of these are also regulated in normal mouse thymocytes.

International audience; Physiological studies have shown that the epidermal head and arm lines in cephalopods are a mechanoreceptive system that is similar to the fish and amphibian lateral lines (Budelmann BU, Bleckmann H. 1988). A lateral line analogue in cephalopods: Water waves generate microphonic potentials in the epidermal head lines of Sepia officinalis and Lolliguncula brevis. J. Comp. Physiol. A, 164: 1–5. . A lateral line analogue in cephalopods: Water waves generate microphonic potentials in the epidermal head lines of Sepia officinalis and Lolliguncula brevis. J. Comp. Physiol. A 164:1–5.); however, the biological significance of the epidermal lines remains unclear. To test whether cuttlefish show behavioural responses to local water movements, juvenile Sepia officinalis were exposed to local sinusoidal water movements of different frequencies (0.01–1000 Hz) produced by a vibrating sphere. Five behavioural responses were recorded: body pattern changing, moving, burrowing, orienting, and swimming. Cuttlefish responded to a wide range of frequencies (20–600 Hz), but not to all of the frequencies tested within that range. No habituation to repeated stimuli was seen. Results indicate that cuttlefish can detect local water movements (most likely with the epidermal head and arm lines) and are able to integrate that information into behavioural responses.

This study focused on expression of estradiol receptors (ER) during the estrous cycle. Labeling for ERalpha or beta antigens and luteinizing hormone (LH) or follicle-stimulating hormone (FSH) beta-subunits was done on freshly dispersed pituitary cells. The lowest expression of ERalpha and beta was seen in estrus (23% and 12%, respectively). Expression increased to 42-54% of pituitary cells by diestrus. In males, cells with ERalpha or beta were 37% or 20% of the population, respectively. ERalpha or beta and gonadotropin antigens were in 6-9% of pituitary cells from male rats. Early in the cycle (estrus and metestrus), less than 5% of pituitary cells expressed ERalpha or beta with gonadotropins. These values doubled to reach a peak of 10% during proestrus (just before ovulation). These data show that a rise in expression of both ERalpha and ERbeta is a part of preovulatory differentiation of pituitary gonadotropes.(J Histochem Cytochem 49:665-666, 2001)

The introduced mosquitofish (Gambusia affinis holbrooki) is a pest species in Australia and has been implicated in the decline of populations of native fishes and anurans. However, few quantitative data exist regarding interactions between Gambusia and native aquatic fauna. We used replicated laboratory experiments to investigate predation by G. a. holbrooki on eggs, hatchlings and tadpoles of native (Limnodynastes ornatus) and non-native (Bufo marinus) anurans. Our aims were to determine (1) whether the susceptibility of anurans to predation by G. a. holbrooki changes during larval development, and (2) the potential for G. a. holbrooki as a predator of the introduced toad B. marinus. Gambusia were significant predators of all aquatic life-history stages of L. ornatus, but were significant predators of B. marinus only at the hatchling stage. When offered both species simultaneously, Gambusia consumed tadpoles of L. ornatus but avoided those of B. marinus. The differences between the responses of Gambusia to L. ornatus and B. marinus are probably due to differences in palatability and toxicity of eggs, hatchlings and tadpoles of these species. The results indicate that G. a. holbrooki is unlikely to significantly affect larval populations of B. marinus via predation. However, Gambusia has the potential to significantly affect larval populations of L. ornatus in natural water bodies where these species co-occur.