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Major thermal burn injuries result in approximately 40,000 hospitalizations in the United States each year. Chronic pain affects up to 60% of burn survivors, and Black Americans have worse chronic pain outcomes than White Americans. Mechanisms of chronic pain pathogenesis after burn injury, and accounting for these racial differences, remain poorly understood. Due to socioeconomic disadvantage and differences in skin absorption, Black Americans have an increased prevalence of Vitamin D deficiency. We hypothesized that peritraumatic Vitamin D levels predict chronic pain outcomes after burn injury and contribute to racial differences in pain outcomes. Among burn survivors (n = 77, 52% White, 48% Black, 77% male), peritraumatic Vitamin D levels were more likely to be deficient in Blacks vs Whites (27/37 [73%] vs 14/40 [35%], P < .001). Peritraumatic Vitamin D levels were inversely associated with chronic post-burn pain outcomes across all burn injury survivors, including those who were and were not Vitamin D deficient, and accounted for approximately one-third of racial differences in post-burn pain outcome. Future studies are needed to evaluate potential mechanisms mediating the effect of Vitamin D on post-burn pain outcomes and the potential efficacy of Vitamin D in improving pain outcomes and reducing racial differences. [ABSTRACT FROM AUTHOR]

Ethnic and gender disparities in healthcare have been well described. Increasing attention is paid to representative diversity in the images and educational resources used during medical training. Nearly 40% of the population of the United States identifies as a person of color, and patients of color reflect 41% of the total burn population seen in the United States. Additionally, national data on providers suggest about 5% of the Burn Team should be people of color. A better understanding of the diversity represented by burn-related medical literature could affect the management of patients with diverse backgrounds, as well as recruitment of black, indigenous, and people of color (BIPOC) into this field. The goal of this study is to investigate the representation of diverse skin tones in several leading medical textbooks of burn care. All photographs that contained people were evaluated for the number of people present and the depicted role of the person present. Diversity count was assessed in a binary fashion-was the individual represented a BIPOC? About 2579 total individuals were identified. BIPOC was represented in 363 total images (14%). There were 6 providers of color identified out of a total of 161 (3.7%); 30 providers were women (19%), of whom only 1 was a female provider of color. BIPOC patients and providers are underrepresented in the leading textbooks of burn care. Proper representation must be included in modern educational materials to better prepare providers for a diverse population of burn-injured patients and ensure effective and thoughtful care. [ABSTRACT FROM AUTHOR]

Hospital readmission data may be a useful tool in identifying risk factors leading to higher costs of care or poorer overall outcomes. Several studies have emerged utilizing these datasets to examine the trauma and burn population, which have been unable to distinguish planned from unplanned readmissions. The 2014 Nationwide Readmissions Database was queried for 363 burn-specific ICD-9 DX codes and filtered by age and readmission status to capture the adult burn population. Additionally, burn-related excision and grafting procedures were filtered from 25 ICD-9 SG codes to distinguish planned readmissions. A total of 26,719 burn patients were identified with 781 all-cause unscheduled 30-day readmissions. Further filtering by burn-related excision and grafting procedures then identified 468 patients undergoing a burn-related excision and grafting procedure on readmission, reducing the dataset to 313 patients and identifying up to 60% of readmissions as possibly improperly coded planned readmissions. From this dataset, nonoperative management on initial admission was found to have the strongest correlation with readmission (OR 5.00; 3.33-7.14). Notably corrected data, when stratified by annual burn patient admission volume, identified a significant likelihood of readmission (OR 4.57; 2.15-9.70) of centers receiving the lowest annual number of burn patients, which was not identified in the unfiltered dataset. Healthcare performance statistics may be a powerful metric when utilized appropriately; however, these databases must be carefully applied to small and special populations. This study has determined that as many as 60% of burn patient readmissions included in prior studies may be improperly coded planned readmissions. [ABSTRACT FROM AUTHOR]

On August 27 and 28, 2018, the American Burn Association, in conjunction with Underwriters Laboratories, convened a group of experts on burn and inhalation injury in Washington, DC. The goal of the meeting was to identify and discuss the existing knowledge, data, and modeling gaps related to understanding cutaneous thermal injury and inhalation injury due to exposure from a fire environment, and in addition, address two more areas proposed by the American Burn Association Research Committee that are critical to burn care but may have current translational research gaps (inflammatory response and hypermetabolic response). Representatives from the Underwriters Laboratories Firefighter Safety Research Institute and the Bureau of Alcohol, Tobacco, Firearms and Explosives Fire Research Laboratory presented the state of the science in their fields, highlighting areas that required further investigation and guidance from the burn community. Four areas were discussed by the full 24 participant group and in smaller groups: Basic and Translational Understanding of Inhalation Injury, Thermal Contact and Resulting Injury, Systemic Inflammatory Response and Resuscitation, and Hypermetabolic Response and Healing. A primary finding was the need for validating historic models to develop a set of reliable data on contact time and temperature and resulting injury. The working groups identified common areas of focus across each subtopic, including gaining an understanding of individual response to injury that would allow for precision medicine approaches. Predisposed phenotype in response to insult, the effects of age and sex, and the role of microbiomes could all be studied by employing multi-omic (systems biology) approaches. [ABSTRACT FROM AUTHOR]

Introduction Racial and gender disparities in health care have been well described. The Association of American Medical Colleges states they are committed to diversity, equity, and inclusion in preparing medical trainees. Increasing attention is paid to representative diversity in the images and educational resources utilized during medical training. One recent example of this is the Instagram account, "Brown Skin Matters," that focuses on the representation of dermatologic diseases in the skin of people of color. Nearly 40% of the population of the United States identifies as a person of color, and patients of color reflect 41% of the total burn population seen in the United States. In comparison, national data on providers suggests about 5% of the Burn Team would be people of color. As representation matters, a better understanding of the diversity represented by burn related medical literature could affect management of patients with diverse backgrounds and recruitment into this field. The goal of this study is to investigate the representation of diverse skin tones in the leading medical textbook of burn care. Methods The 5th edition of "Total Burn Care (TBC)", 5th ed, DN Herndon editor, was reviewed from cover to cover. All photographs that contained people were evaluated for the number of people present and the depicted role of person present (i.e.: provider, patient or other). Each picture was considered as an isolated image, regardless of whether it was part of a series. Diversity count was assessed in a binary fashion - was the individual represented a person of color or not? Additional information was collected on the gender of providers present. Results 690 total individuals were identified in images in TBC. There were 3 providers of color identified in TBC images out of a total of 63(5%); 24 providers were women (38%), of whom none were women providers of color. People of color were represented in 107 of 627 non-providers shown in TBC (17%). There were 29 patients whose skin color was unable to be evaluated due to the nature of the injury, the quality of the image or the surface area of dressings visualized in the image (5%). Conclusions Both patients and providers of color are underrepresented in the leading textbook of burn care. Proper representation must be included in modern educational materials to better prepare providers for a diverse population of burn injured patients and appropriately address injury identification, wound healing properties, and scar outcomes. Diverse and proportional representation of potential outcomes needs to be a component of educational materials. to ensure effective and thoughtful care. [ABSTRACT FROM AUTHOR]

More than half of individuals experiencing major thermal burn injury (MThBI) receive an autologous skin graft (autograft), in which skin is removed from a healthy "donor" site and transplanted to the burn site. Persistent pain and itch at the graft site are major causes of suffering and disability in MThBI survivors. African Americans have a higher risk of MThBI, and in other clinical settings African Americans experience a greater burden of pain and itch relative to European Americans. However, to our knowledge, ethnic differences in skin graft site pain and itch outcomes after MThBI have not been assessed. We evaluated skin graft site pain and itch severity (0-10 Numeric Rating Scale [NRS]) over 1 year in a prospective multicenter cohort sample of African Americans and European Americans. In adjusted linear mixed models, African Americans experienced a slower rate of pain resolution in the acute phase of recovery (β = -0.05 vs -0.08 NRS points per day, P < 0.001), which resulted in a higher pain severity in the persistent phase of recovery (NRS mean difference = 1.21, 95% confidence interval [0.12-2.29]), although not statistically significant after correction for multiple comparisons. African Americans also experience greater itch severity in 6 weeks to 12 months after burn injury compared with European Americans (NRS mean difference = 1.86 [0.80-2.93]), which results from a faster rate of itch development in African Americans in the acute recovery phase after burn injury. Future studies may improve outcomes in African Americans and lead to new pathogenic insights that benefit all burn injury survivors. [ABSTRACT FROM AUTHOR]

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a pathogen that can result in substantial morbidity and mortality. Early detection of MRSA colonization by screening nasal swabs may be important in the management of burn-injured patients. However, studies examining its use in this population are limited. The aim of this study was to study the utility of admission MRSA screening nasal swabs and determine if being positive for MRSA on admission impacted outcomes.Materials and Methods: A retrospective review was conducted of burn patients who presented to a single regional burn center between June 2012 and December 2014. Electronic medical records and charts were reviewed for patient demographics and management. MRSA screening swabs were obtained from the anterior nares of burn patients upon admission. Patients without a MRSA nasal swab within 48h of admission were excluded. Outcomes analyzed included overall length of stay, ICU admission and length of stay, mechanical ventilation, procedure count, time to excision, and wound complications after normalizing to total body surface area burn size (%TBSA).Results: During the study period, 601 patients received a MRSA screening nasal swab upon admission. Of these, 24 patients screened positive for MRSA (4%). Patients who screened positive for MRSA had a significantly increased mean length of stay (3.95v 2.36 days; p<0.05) and number of surgical procedures (1.92v 1.06; p<0.05). Positively screened patients also had a higher proportion of wound infections (50% v 18.2%; p<0.05), half of which were caused by MRSA. Subsequent graft complications were seen in 50% of patients with a wound complication. Only 2 positively screened patients were started on empiric antibiotics.Conclusions: Burn patients who screened positive for MRSA had greater lengths of stay, more surgical procedures, and higher wound complications. Early identification of MRSA colonized patients in this patient population might allow for treatment modifications that improve outcomes. Further study is warranted in a prospective clinical trial. [ABSTRACT FROM AUTHOR]

To better understand trends in burn treatment patterns related to definitive closure, this study sought to benchmark real-world survey data with national data contained within the National Burn Repository version 8.0 (NBR v8.0) across key burn center practice patterns, resource utilization, and clinical outcomes. A survey, administered to a representative sample of U.S. burn surgeons, collected information across several domains: burn center characteristics, patient characteristics including number of patients and burn size and depth, aggregate number of procedures, resource use such as autograft procedure time and dressing changes, and costs. Survey findings were aggregated by key outcomes (number of procedures, costs) nationally and regionally. Aggregated burn center data were also compared to the NBR to identify trends relative to current treatment patterns. Benchmarking survey results against the NBR v8.0 demonstrated shifts in burn center patient mix, with more severe cases being seen in the inpatient setting and less severe burns moving to the outpatient setting. An overall reduction in the number of autograft procedures was observed compared to NBR v8.0, and time efficiencies improved as the intervention time per TBSA decreases as TBSA increases. Both nationally and regionally, an increase in costs was observed. The results suggest resource use estimates from NBR v8.0 may be higher than current practices, thus highlighting the importance of improved and timely NBR reporting and further research on burn center standard of care practices. This study demonstrates significant variations in burn center characteristics, practice patterns, and resource utilization, thus increasing our understanding of burn center operations and behavior., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Burn Association.)

Background: Although racial disparities have been well described in trauma and medical literature, less is known about disparities in the burn population, especially the Native American, Hispanic, Black, and Asian minority groups. This study seeks to identify at-risk populations for differences in patient and social characteristics that may link certain race groups to disparate burn outcomes., Methods: Data was reviewed from the National Burn Repository. Information regarding patient demographics, co-morbidities, complications, and clinical outcomes was recorded. Student's T-test, ANOVA, and binary logistic regression were used to assess relationships between patient factors and outcomes., Results: The Native American cohort had higher rates of alcoholism, drug abuse, and homelessness compared to all patients. Native Americans also had significantly longer hospital lengths of stay, and higher rates of respiratory failure, pneumonia, sepsis, and wound complications. The Black population demonstrated the highest percentage of injury at home, child abuse, and non-insurance. Mortality was highest in the Black population compared to all patients., Conclusions: These findings suggest that outcome disparities exist in burn-injured patients in multiple minority groups., (Copyright © 2018 Elsevier Inc. All rights reserved.)

There is a paucity of information in the peer-reviewed literature characterizing the current burn surgeon workforce and compensation potential, and, in a parallel topic, training opportunities and recruitment methods. What does exist documents minimal exposure to the field and surgeon shortages. A comprehensive survey was created to address 1) the demographics of current burn surgeons in practice, and 2) the structure of burn centers training models. Finally, three questions were asked regarding job satisfaction. With a response rate of 23%, demographics reflect representative involvement across the age spectrum. The majority of respondents (73.9%) had training in general surgery, with subsequent postgraduate training primarily in surgical critical care or burn fellowships. Two-thirds of respondents have active practices, cover multiple specialties, and take multispecialty call throughout the month. A variety of models are used to calculate compensation. The vast majority of burn centers train residents: general surgery residents (89%), plastic surgery residents (63%), and emergency medicine residents (32%), most of whom are in their first 3 years of training. The majority of respondents would become a burn surgeon again if they had to do it over and would recommend it to young surgeons as a career. A representative sample of burn surgeons from across North America sustains practices in similar ways. Access to the next generation of surgeons is at an early period in training (PGY1-3) which may prove valuable as surgical education evolves. Overall, burn surgeons express good job satisfaction, a significant point of interest as attention turns towards succession planning.

Approximately three quarters of major thermal burn injury (MThBI) survivors suffer from hypertrophic scarring (HTS) and over half experience chronic pain or itch. In survivors of MThBI, HTS and chronic pain or itch are considered one of the greatest unmet challenges of postburn injury care and psychosocial reintegration. Although scarring, itch, and pain have been clinically associated, there are no prospective, multisite studies examining tissue autograft site pain or itch and scar outcomes. The authors collected a representative cohort (n = 56) of MThBI survivors who received autografting within 14 days of injury and evaluated graft-site pain or itch severity (0-10 Numeric Rating Scale) and HTS using a validated scar photograph assessment scale 6 months following MThBI. Given that stress is known to influence wound healing, the authors also assessed the relationship between previous trauma exposure, peritraumatic stress, preburn overall health (SF-12), scarring, and chronic pain or itch severity using Spearman's correlation. Association between HTS and chronic pain or itch was significant in a linear regression model adjusted for age, sex, and ethnicity (β = 0.2, P = .033 for pain, β = 0.2, P = .019 for itch). Results indicate that prior trauma exposure is inversely correlated (r = -.363, P = .030) with scar severity, but not pain or itch severity 6 months after MThBI. Study results suggest that preburn chronic pain or itch is associated with pathological scarring 6 months following MThBI. Results also indicate that stress may improve scarring after MThBI. Further work to understand the mechanisms that underlie both HTS and chronic pain or itch and their relationship to chronic stress is critical to the development of novel therapies to assist burn survivors recover.

Extracorporeal membranous oxygenation (ECMO) has become an increasingly utilized used strategy to support patients in cardiac and cardiopulmonary failure. The Extracorporeal Life Support Organization reports adult survival rates between 40 and 50%. Utilization Use and outcomes for burned patients undergoing ECMO are poorly understood. The National Burn Repository (version 8.0) was queried for patients with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) procedure codes for ECMO. Demographics, comorbidities, mechanism, injury details, and clinical outcomes were recorded. ECMO patients were matched one-to-one to those not requiring ECMO based on age, gender, TBSA, and inhalation injury. Group comparisons were made utilizing using χ2 and Mann-Whitney U tests. Thirty ECMO-treated burn patients were identified. Patients were predominantly male (80.0%) and Caucasian (63.3%) with mean age 38.9 ± 20.3 years. The majority were flame injuries (80.0%) of moderate size (17.0 ± 18.7% TBSA), affecting predominantly upper limbs and trunk. Inhalation injury was reported in 26.7%. Respiratory failure was reported in nine, acute respiratory distress syndrome in three, and pneumonia in nine. Fourteen patients survived to discharge. The ECMO cohort had significantly higher rates of cardiovascular comorbidities, concomitant major thoracic trauma, pneumonia, acute renal failure, and sepsis than non-ECMO patients (P < .05). Ventilator usage, intesive care unit (ICU) length of stay, and mortality were also significantly higher in those treated by ECMO (P < .05). Although burn patients placed on ECMO have significantly higher rates of morbidity and mortality than those not requiring ECMO, the mortality rate is equivalent to patients reported by Extracorporeal Life Support Organization. ECMO is a viable option for supporting critically injured burn patients.

The affect of paralysis-related comorbidities on outcomes in burn-injured patients has not been explored. We hypothesize that comorbid paralysis is associated with increased morbidity in this population. All burned patients with prior diagnoses of paralysis were identified from the National Burn Repository (Version 8.0). One-to-one matching of nonparalyzed burn-injured patients was performed, and nonparametric analysis was used to compare the groups. We identified 432 paralyzed patients, who were predominantly male (70.6%) and Caucasian (57.6%), with an average age of 40.8 ± 19.0 years. The identified level of disability was distinguished as paraplegia (59.5%), hemiplegia (16.9%), quadriplegia (13.9%), or other (9.8%). A majority of injuries occurred in the home (75.2%), primarily due to scalds (48.1%). More than half sustained small injuries with affected total body surface area <5%. Lower extremities were frequently injured (72.2%), with 41.0% affecting exclusively the lower extremities. While the paralysis population had significantly longer hospital lengths of stay, nonparalyzed patients had longer intensive care unit length of stay and ventilator days (P < .001). There was no statistically significant difference in mortality rate between paralyzed and nonparalyzed patients (4.4% vs 4.9%, P = .550). Patients with paralysis are susceptible to small scald injuries in the home. Comorbid paralysis places patients at risk for longer, more indolent hospital stays, when compared with matched nonparalyzed patients with more critical illness. Further investigation is needed regarding the pathophysiologic mechanisms predisposing paralyzed burn patients to increased morbidity.

Survival rates of burn patients have increased greatly over the past several decades. There are, however, still patients with relatively small burns who do not survive their hospitalizations. This work aimed to elucidate factors common to this select subset of patients. The NBR Main dataset was queried for record numbers associated with TBSA between 0.1 and 10 and a discharge status indicating death. Using SAS statistical software, the patients were matched for age, sex, and TBSA. Chi-square analyses of independence on categorical variables and unpaired, two-tailed Students' t-tests with unequal variance on continuous variables were used to identify fields of further interest. SAS was then used to build multivariate logistic regression models examining variables affecting discharge status. The NBR complications child dataset was queried and categorized for the types of complications for analysis. Multivariate logistic regression for discharge status, comorbidities, and complications showed that the presence of a complication significantly impacted discharge status. The presence of an identified complication (other than death) increased the odds ratio of a discharge status of death by a factor of 3.023 (95% confidence interval [2.306, 3.964], P < .0001). Pulmonary and infection-related complications were the most frequently seen across all the records analyzed, but infection-related complications did not reach statistical significance in relation to discharge status. Multivariate logistic regression of complications in a model for discharge status identified four categories as statistically significant: neurologic, cardiovascular, pulmonary, and renal. In patients with small TBSA burns, the presence of complications significantly increases the odds ratio of death as judged by the NBR data. The complications which appear to be of particular interest are cardiovascular, neurologic, renal, and pulmonary, and those patients who are likely most susceptible to these complications are those with inhalation injury in addition to their cutaneous burns.

Little is known about the nutritional needs of obese burn patients. Given the impact of obesity on the morbidity and mortality of these patients, a uniform understanding of perceptions and practices is needed. To elucidate current practices of clinicians working with the obese burn population, the authors constructed a multidisciplinary survey designed to collect this information from practitioners in United States burn centers. An electronic approach was implemented to allow for ease of distribution and completion. A portable document format (pdf) letter was e-mailed to the members of the American Burn Association and then mailed separately to additional registered dietitians identified as working in burn centers. This letter contained a link to a 29-question survey on the SurveyMonkey.com server. Questions took the form of multiple choice and free text entry. Responses were received from physicians, mid-level practitioners, registered dietitians, and nurses. Seventy-five percent of respondents defined obesity as body mass index >30. The Harris-Benedict equation was identified as the most frequently used equation to calculate the caloric needs of burn patients (32%). Fifty-eight percent indicated that they alter their calculations for the obese patient by using adjusted body weight. Calculations for estimated protein needs varied among centers. The majority did not use hypocaloric formulas for obese patients (79%). Enteral nutrition was initiated within the first 24 hours for both obese and nonobese patients at most centers. Sixty-three percent suspend enteral nutrition during operative procedures for all patients. Oral feeding of obese patients was the most preferred route, with total parenteral nutrition being the least preferred. Longer length of stay, poor wound healing, poor graft take, and prolonged intubation were outcomes perceived to occur more in the obese burn population. In the absence of supporting research, clinicians are making adjustments to the nutritional care of obese burn patients. This indicates the need for further research to determine consistent best practices.

Length of stay (LOS) continues to be a standard variable when evaluating progress and outcomes in burn care. Common wisdom would dictate that this measure is linearly related to TBSA. Is this truly the case? A retrospective review of the National Burn Repository was conducted to evaluate factors that affect hospital LOS. The National Burn Repository data set was obtained from the American Burn Association. Data from the years 2002-2007 were extracted. Unique patients were identified by removing readmissions, outpatients, and patients not admitted. Patients whose "HOSPLOS" and/or "AREATOT" field was blank or 0 were excluded, as were nonthermally injured patients. Patients without an entry for age and dead patients were also excluded. This left a final data set of 52,712 patients for analysis. The data were then analyzed, with %TBSA burned as the independent variable. In patients who survived their entire LOS, the mean LOS increased linearly by decile. Females with a TBSA <40% have a trend toward increased LOS relative to their male counterparts of the same TBSA; however, this trend reverses for TBSA ≥40%. Age alone is not a significant predictor of increasing LOS. The cause of burns was predominantly flame related across all deciles of TBSA, and most etiologies for burn demonstrate the predicted increase in LOS per %TBSA. LOS was not significantly affected by insurance type or whether the injury was work related or not. This analysis was confounded by the small numbers of patients with burns >60% and age older than 70 years. Anticipating hospital LOS is not a simple task. Using complex statistical analysis, a linear trend associated with %TBSA can be seen; however, other variables do contribute. Until the precise role of these variables can be elucidated, anticipating patient LOS to be 1 day for every %TBSA is still a useful exercise.

Bloodstream infections (BSIs) are a major cause of morbidity and mortality in thermally injured patients. However, these infections have not been well defined in this patient population. Therefore, the authors performed a retrospective case-control study to characterize the epidemiology, microbiology, and outcomes of burn-associated BSIs. A retrospective review of all patients in the National Burn Repository (NBR) between the years 1981 and 2007 was performed. All cases that had infection listed under complications were included in this study. For each case, two randomly selected patients from the same time period served as controls. Patient demographic data, extent of %TBSA, and type of infection were extracted. Primary end point was mortality. Secondary endpoints were hospital length of stay (LOS), intensive care unit LOS, total ventilator days, and hospital charges. Further analysis of the data involved case-matching patients by TBSA deciles, adjustment for the effects of TBSA and other potential confounders, and a sensitivity analysis of the effects of including or excluding sites that might have failed to consistently capture BSI information. A total of 11,793 patients (3931 cases and 7862 control) were included in the study. Of cultures revealing a Gram-positive organism, Staphylococcus aureus (32%) was the most common. From samples where isolation of a Gram-negative species occurred, Pseudomonas aeruginosa (35%) was more prominent. Infected patients were older (40.9 vs 32.8, P < .05) and had higher %TBSA (22.2 vs 7.9, P < .05). BSI was associated with significantly higher mortality (21.9% vs 3.09%), hospital LOS (47.4 vs 8.8 days) intensive care unit LOS (30.8 vs 2.6 days), ventilator days (29.2 vs 1.4 days), and hospital charge ($339,909.91 vs $33,272.43); P < .001 for all values. On evaluation of case-matched controls, mortality was higher for patients with BSI only <50% TBSA strata. Conclusions were unaffected by adjustment for TBSA and other possible confounders and was not influenced by possible failure of some sites to consistently capture BSI information. Development of BSI in hospitalized burn patients is associated with significant increases in morbidity, mortality, and resource utilization.