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The effects of stakeholder engagement, particularly in comparative effectiveness trials, have not been widely reported. In 2014, eight comparative effectiveness studies targeting African Americans and Hispanics/Latinos with uncontrolled asthma were funded by the Patient-Centered Outcomes Research Institute (PCORI) as part of its Addressing Disparities Program. Awardees were required to meaningfully involve patients and other stakeholders. Using specific examples, we describe how these stakeholders substantially changed the research protocols and in other ways participated meaningfully as full partners in the development and conduct of the eight studies.Using the method content analysis of cases, we identified themes regarding the types of stakeholders, methods of engagement, input from the stakeholders, changes made to the research protocols and processes, and perceived benefits and challenges of the engagement process. We used summaries from meetings of the eight teams, results from an engagement survey, and the final research reports as our data source to obtain detailed information. The descriptive data were assessed by multiple reviewers using inductive and deductive qualitative methods and discussed in the context of engagement literature.Stakeholders participated in the planning, conduct, and dissemination phases of all eight asthma studies. All the studies included clinicians and community representatives as stakeholders. Other stakeholders included patients with asthma, their caregivers, advocacy organizations, and health-system representatives. Engagement was primarily by participation in advisory boards, although six of the eight studies (75%) also utilized focus groups and one-on-one interviews. Difficulty finding a time and location to meet was the most reported challenge to engagement, noted by four of the eight teams (50%). Other reported challenges and barriers to engagement included recruitment of stakeholders, varying levels of enthusiasm among stakeholders, controlling power dynamics, and ensuring that stakeholder involvement was reflected and had true influence on the project.Engagement-driven modifications led to specific changes in study design and conduct that were felt to have increased enrollment and the general level of trust and support of the targeted communities. The level of interaction described, between investigators and stakeholders in each study and between investigator-stakeholder groups, is-we believe-unprecedented and may provide useful guidance for other studies seeking to improve the effectiveness of community-driven research.The goal of comparative clinical effectiveness research is to compare healthcare options and learn which work best for patients depending on their preferences and circumstances. Research efforts can be more effective when researchers engage stakeholders, such as patients, healthcare providers, and other members of the community—especially those communities or groups targeted by the planned research. Stakeholders can give their input throughout the research process to make sure the study will address questions and concerns that are most important and useful for participants. In 2014, the PCORI funded eight research studies that evaluated various ways to help African Americans and Hispanics/Latinos with poorly controlled asthma. These groups are underrepresented in asthma research but have higher rates of and more severe asthma for reasons that are poorly understood. The goal of this report is to show how stakeholders—including patients with asthma from these underrepresented groups, healthcare providers who care for patients with asthma, key representatives from the communities and others—participated as full partners in the eight studies and helped to improve the overall quality of the research and the relationship between the researchers and the community.

OBJECTIVE Washington State's HealthPact program was launched in 2011 as part of AHRQ's Patient Safety and Medical Liability Reform initiative. HealthPact delivered interdisciplinary communication training to health-care professionals with the goal of enhancing safety. We conducted 2 exploratory, retrospective database analyses to investigate training impact on the frequency of adverse events (AEs) and select quality measures across 3 time frames: pretraining (2009-2011), transition (2012), and posttraining (2013). METHODS Using administrative data from Washington State's Comprehensive Hospital Abstract Reporting System (CHARS) and clinical registry data from the Surgical Care and Outcomes Assessment Program (SCOAP), we compared proportions of AEs and quality measures between HealthPact (n = 4) and non-HealthPact (n = 93-CHARS; n = 48-SCOAP) participating hospitals. Risk ratios enabled comparisons between the 2 groups. Multivariable logistic regression enabled investigation of the association between training and the frequency of AEs. RESULTS Approximately 9.4% (CHARS) and 7.7% (SCOAP) of unique patients experienced 1 AE or greater. In CHARS, the odds of a patient experiencing an AE in a HealthPact hospital were initially (pretraining) higher than in a non-HealthPact hospital (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.10-1.17), lower in transition (OR, 0.80; 95% CI, 0.76-0.83) and posttraining (OR, 0.72; 95% CI, 0.69-0.75) periods. In SCOAP, ORs were consistently lower in HealthPact hospitals: pretraining (OR, 0.87; 95% CI, 0.80-0.95), transition (OR, 0.75; 95% CI, 0.70-0.81), and posttraining (OR, 0.63; 95% CI, 0.58-0.68). The proportion of at-risk patients that experienced each individual AE was low (

Background: As climate change is expected to result in more frequent, larger fires and associated smoke impacts, creating and sustaining wildfire smoke-resilient communities is an urgent public health priority. Following two summers of persistent and extreme wildfire smoke events in Washington state, the need for additional research on wildfire smoke health impacts, risk communication, and risk reduction, and an associated greater coordination between researcher and practitioner communities, is of paramount importance. Objectives: On 30 October 2018, the University of Washington hosted a Wildfire Smoke Risk Communication Stakeholder Synthesis Symposium in Seattle, Washington. The goals of the symposium were to identify and prioritize practice-based information gaps necessary to promote effective wildfire smoke risk communication and risk reduction across Washington state, foster collaboration among practitioners and academics to address information gaps using research, and provide regional stakeholders with access to the best available health and climate science about current and future wildfire risks. Methods: Seventy-six Washington state practitioners and academics with relevant professional responsibilities or expertise in wildfire smoke and health engaged in small group discussions using the &ldquo, World Caf&eacute, Method&rdquo, to identify practice-relevant research needs related to wildfire smoke and health. Notes from each discussion were coded and qualitatively analyzed using a content analysis approach. Discussion: Washington state&rsquo, s public health and air quality practitioners need additional evidence to communicate and reduce wildfire smoke risk. Exposure, health risk, risk communication, behavior change and interventions, and legal and policy research needs were identified, along with the need to develop research infrastructure to support wildfire smoke and health science. Practice-relevant, collaborative research should be prioritized to address this increasing health threat.

Background African-American and Latino patients are often difficult to recruit for asthma studies. This challenge is a barrier to improving asthma care and outcomes for these populations. Objectives We sought to examine the recruitment experiences of 8 asthma comparative effectiveness studies that specifically targeted African-American and Latino patients, and identify the solutions they developed to improve recruitment. Methods Case report methodology was used to gather and evaluate information on study design, recruitment procedures and outcomes from study protocols and annual reports, and in-depth interviews with each research team. Data were analyzed for themes, commonalities, and differences. Results There were 4 domains of recruitment challenges: individual participant, institutional, research team, and study intervention. Participants had competing demands for time and some did not believe they had asthma. Institutional challenges included organizational policies governing monetary incentives and staff hiring. Research team challenges included ongoing training needs of recruitment staff, and intervention designs often were unappealing to participants because of inconveniences. Teams identified a host of strategies to address these challenges, most importantly engagement of patients and other stakeholders in study design and troubleshooting, and flexibility in data collection and intervention application to meet the varied needs of patients. Conclusions Asthma researchers may have greater success with recruitment by addressing uncertainty among patients about asthma diagnosis, engaging stakeholders in all aspects of study design and implementation, and maximizing flexibility of study and intervention protocols. However, even with such efforts, engagement of African-American and Latino patients in asthma research may remain low. Greater investment in research on engaging these populations in asthma research may ultimately be needed to improve their asthma care and outcomes.

An understanding of population-specific variation in pediatric burn injuries is essential to the development of effective prevention strategies. The purpose of this study was to examine the etiology of pediatric burn injury considering age and race categories using the National Burn Repository. The authors reviewed the records of all pediatric patients (age

Although comprehensive burn care requires significant resources, patients may be treated at verified burn centers, nonverified burn centers, or other facilities due to a variety of factors. The purpose of this study was to evaluate the association between patient and injury characteristics and treatment location using a national database.We performed an analysis of all burn patients admitted to United States hospitals participating in the Healthcare Cost and Utilization Project over 2 years. Univariate and multivariate analyses were performed to identify patient and injury factors associated with the likelihood of treatment at designated burn care facilities. Definitive care facilities were categorized as American Burn Association-verified centers, nonverified burn centers, or other facilities.During the 2 years of the study, 29,971 burn patients were treated in 1,376 hospitals located in 19 participating states. A total of 6,712 (22%) patients were treated at verified centers, with 26% and 52% treated at nonverified or other facilities, respectively. Patients treated at verified centers were younger than those treated at nonverified or other facilities (33.1 years versus 33.7 years versus 41.9 years; p0.001) and had a higher rate of inhalation injury (3.4% versus 3.2% versus 2.2%; p0.001). Independent factors associated with treatment at verified centers include burns to the head or neck (relative risk [RR], 2.4; CI, 2.1 to 2.7), hand (RR, 1.8; CI, 1.6 to 1.9), electrical injury (RR, 1.4; CI, 1.2 to 1.7), and fewer comorbidities (RR, 0.55; CI, 0.5 to 0.6).More than two-thirds of significantly burned patients are treated at nonverified burn centers in the United States. Many patients meeting American Burn Association criteria for transfer to a burn center are being treated at nonburn center facilities.

Older adults with burns are at risk for worse outcomes because of factors related to age, comorbidities, and response to treatment. Although the impact of pneumonia has been previously described in burn patients, less is known in the older adult population. In this study, we used the National Burn Repository to characterize patient and injury factors associated with pneumonia development in older adults with burns. We examined the records of all patients in the National Burn Repository aged 55 years and older from 1995 to 2007. To better characterize the effects of age on outcomes, patients were stratified into three categories: 55 to 64 years, 65 to 74 years, and 75 years and older. Pneumonia was identified by listed complications and ICD-9 codes. Comorbidities were classified by Charlson Comorbidity Index Score. Unadjusted and multivariate regression analyses were performed to distinguish the impact of age, comorbidities, and injury factors on pneumonia development and mortality. A total of 23,794 patient records met inclusion criteria during the study period, and 2,052 (8.6%) had pneumonia. Patients who developed pneumonia were more likely to be men (65 vs 56%, P < .001), have higher TBSA (21 vs 13%, P < .001), have sustained inhalation injury (21 vs 7%, P < .001), and have comorbid condition (34 vs 13%, P < .001). On multivariate analysis, factors significantly associated with pneumonia development were male sex, percent TBSA, inhalation injury, and presence of comorbidity. Specifically, chronic lung and heart disease had adjusted odds ratio (OR) of 2.70 and 3.48, respectively, for development of pneumonia (P < .001). By logistic regression, adjusted OR for pneumonia were 0.89 (95% CI 0.74–1.06, P = 18) in the 65 to 74 years age group and 1.26 (95% CI 1.07–1.48, P = 005) in the oldest group compared with the 55 to 64 years age group. Pneumonia during hospitalization was associated with an adjusted OR of 1.91 for death (95% CI 1.61–2.27, P < .001) after controlling for the factors of age, sex, comorbidity, TBSA, and inhalation injury. Injury factors and the presence of comorbidities consistently predicted the development of pneumonia in this large national patient sample. Higher age category also predicted higher pneumonia risk, although this association was only significant in the highest age group. This study, thus, highlights the importance of comorbidities over chronological age in pneumonia development in older adults with burn injuries. (J Burn Care Res 2010;31:105–110)

In 2002, the U.S. Environmental Protection Agency (EPA) released an "Interim Policy on Genomics," stating a commitment to developing guidance on the inclusion of genetic information in regulatory decision making. This statement was followed in 2004 by a document exploring the potential implications. Genetic information can play a key role in understanding and quantifying human susceptibility, an essential step in many of the risk assessments used to shape policy. For example, the federal Clean Air Act (CAA) requires EPA to set National Ambient Air Quality Standards (NAAQS) for criteria pollutants at levels to protect even sensitive populations from adverse health effects with an adequate margin of safety. Asthmatics are generally regarded as a sensitive population, yet substantial research gaps in understanding genetic susceptibility and disease have hindered quantitative risk analysis. This case study assesses the potential role of genomic information regarding susceptible populations in the NAAQS process for fine particulate matter (PM 2.5 ) under the CAA. In this initial assessment, we model the contribution of a single polymorphism to asthma risk and mortality risk; however, multiple polymorphisms and interactions (gene-gene and gene-environment) are known to play key roles in the disease process. We show that the impact of new information about susceptibility on estimates of population risk or average risk derived from large epidemiological studies depends on the circumstances. We also suggest that analysis of a single polymorphism, or other risk factor such as health status, may or may not change estimates of individual risk enough to alter a particular regulatory decision, but this depends on specific characteristics of the decision and risk information. We also show how new information about susceptibility in the context of the NAAQS for PM 2.5 5 could have a large impact on the estimated distribution of individual risk. This would occur if a group were consequently identified (based on genetic and/or disease status), that accounted for a disproportionate share of observed effects. Our results highlight certain conditions under which genetic information is likely to have an impact on risk estimates and the balance of costs and benefits within groups, and highlight critical research needs. As future studies explore more fully the relationship between exposure, genetic makeup, and disease status, the opportunity for genetic information and disease status to play pivotal roles in regulation can only increase.

The provision of optimal burn care is a resource-intensive endeavor. The American Burn Association has developed criteria to help guide the decision to refer a patient to a burn center for definitive injury care. The purpose of this study was to compare the patient and injury characteristics of patients admitted to the single verified burn center in Washington State with those treated at other facilities in the state. We performed a retrospective review of all patients admitted to a hospital with a burn injury in Washington State from 1987 to 2005 using the state's discharge database (Comprehensive Hospital Abstract Reporting System). Patient and injury factors of patients admitted to the state's single verified burn center or at other hospitals were compared. Multivariate poisson regression was used to calculate the relative risk of injury and patient factors that were significantly associated with admission to the verified burn center. From 1987 to 2005, a total of 16,531 patients were admitted to a Washington State hospital after burn injury. Of these patients, 8624 (52.2%) were treated definitively at the University of Washington Burn Center. Patients treated at this verified center had larger overall burn size (7.4% vs 4.5% TBSA, P < .001), higher percent full-thickness burn (4.3% vs 1.2%, P < .001), and higher rates of inhalation injury (2.3% vs 1.5%, P = .005). Uninsured status (relative risk = 1.46, 95% confidence interval = 1.4-1.5) was also significantly associated with treatment at the verified burn center. Injury severity and payer status were both found to be independent predictors of treatment at the single verified burn center in Washington. Language: en

The homeless are at an increased risk for traumatic injury, but little is known about the injury etiology and outcome of homeless persons who sustain burn injuries. In this study, we analyze patient and injury characteristics of homeless persons admitted to a regional burn center. This is a retrospective cohort study of patients admitted to our burn center between 1994 and 2005. A total of 3700 adult patients were admitted during the study period and, of these, 72 (1.9%) were homeless. The cohort of homeless patients was compared with domiciled adult patients admitted during the same time period, analyzing baseline patient and injury characteristics and injury outcomes. Overall, homeless patients had more extensive burn injuries than domiciled patients (17.8% vs 11.2%TBSA, P < .001) and overall longer lengths of hospital stay (22 vs 12 days, P < .001). The homeless population also had significantly higher rates of alcohol (80.6% vs 12.8%, P < .001) and drug abuse (59.4% vs 12.8%, P < .001), history of mental illness (45.2% vs 11.0%, P < .001), and injury by assault (13.9% vs 2.0%, P < .001). Homeless patients tended to have more severe injuries; higher rates of substance abuse and mental illness; increased incidence of assault by burning; and longer lengths of hospital stay. Hospitalization of a homeless patient following injury may provide a unique opportunity to address co-occurring substance abuse and mental illness and approach injury prevention to improve patients’ outcomes and reduce injury recidivism.

SGLT2 inhibitors are plausible second-line drugs that provide powerful additional A1c-lowering effects while inducing weight loss without hypoglycemia.

Purpose: To develop and implement a non-invasive immobilization system guided by a dedicated quality assurance (QA) program for dynamic intensity-modulated radiotherapy (IMRT) of intracranial and head and neck disease, with IMRT delivered using the NOMOS Corporation’s Peacock System and MIMiC collimator. Methods and Materials: Thermoplastic face masks are combined with cradle-shaped polyurethane foaming agents and a dedicated quality assurance program to create a customized headholder system (CHS). Plastic shrinkage was studied to understand its effect on immobilization. Fiducial points for computerized tomography (CT) are obtained by placing multiple dabs of barium paste on mask surfaces at intersections of laser projections used for patient positioning. Fiducial lines are drawn on the cradle along laser projections aligned with nasal surfaces. Lateral CT topograms are annotated with a crosshair indicating the origin of the treatment planning and delivery coordinate system, and with lines delineating the projections of superior-inferior field borders of the linear accelerator’s secondary collimators, or with those of the fully open MIMiC. Port films exposed with and without the MIMiC are compared to annotated topograms to measure positional variance (PV) in superior-inferior (SI), right-left (RL), and anterior posterior (AP) directions. MIMiC vane patterns superposed on port films are applied to verify planned patterns. A 12-patient study of PV was performed by analyzing positions of 10 anatomic points on repeat CT topograms, plotting histograms of PV, and determining average PV. Results and Discussion: A 1.5 ± 0.3 mm SD shrinkage per 70 cm of thermoplastic was observed over 24 h. Average PV of 1.0 ± 0.8, 1.2 ± 1.1, and 1.3 ± 0.8 mm were measured in SI, AP, and RL directions, respectively. Lateral port films exposed with and without the MIMiC showed PV of 0.2 ± 1.3 and 0.8 ± 2.2 mm in AP and SI directions. Vane patterns superimposed on port films consistently verified the planned patterns. Conclusion: The CHS provided adequately reproducible immobilization for dynamic IMRT, and may be applicable to decrease PV for other cranial and head and neck external beam radiation therapy.

To verify that optimized dose distributions provided by an intensity-modulated radiation therapy (IMRT) system are delivered accurately to human patients.Anthropomorphic phantoms are used to measure IMRT doses. Four types of verification are developed for: I) system commissioning with beams optimized to irradiate simulated targets in phantoms, II) plans with patient-optimized beams directed to phantoms simulating the patient, III) patient-phantom hybrid plans with patient-optimized beams calculated in phantom without further optimization, and IV) in vivo measurements. Phantoms containing dosimeters are irradiated with patient-optimized beams. Films are scanned and data were analyzed with software. Percent difference between verified and planned maximum target doses is defined as "dose discrepancy" (deltavp). The frequency distribution of type II deltavp from 204 verification films of 92 IMRT patients is fit to a Gaussian. Measurements made in vivo yield discrepancies specified as deltaivp, also fit to a Gaussian.Verification methods revealed three systematic errors in plans that were corrected prior to treatment. Values of [deltavp] for verification type I are2%. Type II verification discrepancies are characterized by a Gaussian fit with a peak 0.2% from the centroid, and 158 [deltavp]5%. The 46 values of [deltavp]5% arise from differences between phantom and patient geometry, and from simulation, calculation, and other errors. Values of [deltavp] for verification III are less than half of the values of [deltavp] for verification II. A Gaussian fit of deltaivp from verification IV shows more discrepancy than the fit of deltavp, attributed to dose gradients in detectors, and exacerbated by immobilization uncertainty.Dosimetric verification is a critical step in the quality assurance (QA) of IMRT. Hybrid Verification III is suggested as a preliminary quality standard for IMRT.

To compare the dosimetry achievable with an intensity modulated radiotherapy (IMR) system to that of stereotactic radiosurgery (SRS) for an irregularly shaped moderate size target. A treatment plan was selected from 109 single fraction SRS cases having had multiple non-coplanar arc therapy using a 6 MV linear accelerator fitted with circular tertiary collimators 1.00 to 4.00 cm in diameter at isocenter. The CT scan with delineated regions of interest was then entered into an IMR treatment planning system and optimized dose distributions, using a back projection technique for dynamic multileaf collimator delivery, were generated with a simulated annealing algorithm. Dose volume histograms (DVH), homogeneity indices (HI), conformity indices (CI), minimum and maximum doses to surrounding highly sensitive intracranial structures, as well as the volume of tissue treated to >80, 50, and 20% of the prescription dose from the IMR plan were then compared to those from the single isocenter SRS plan used and a hypothetical three isocenter SRS plan. For an irregularly shaped target, the IMR plan produced a HI of 1.08 and CI of 1.50 compared to 1.75 and 4.41, respectively, for the single isocenter SRS plan (SRS1) and 3.33 and 3.43 for the triple isocenter SRS plan (SRS3). The maximum and minimum doses to surrounding critical structures were less with the IMR plan in comparison to both SRS plans. However, the volume of non-target tissue treated to >80, 50, and 20% of the prescription dose with the IMR plan was 137, 170, and 163%, respectively, of that treated with the SRS1 plan and 85, 100, and 123% of the volume when compared to SRS3 plan. The IMR system provided more conformal target doses than were provided by the single isocenter or three isocenter SRS plans. IMR delivered less dose to critical normal tissues and provided increased homogeneity within the target volume for a moderate size irregularly shaped target, at the cost of a larger penumbra. Radiat. Oncol. Invest. 6:18–25, 1998. © 1998 Wiley-Liss, Inc.

BACKGROUND: With unprecedented survival rates in modern burn care, there is increasing focus on optimizing long-term functional outcomes. However, 3% to 8% of patients admitted to burn centers still die of injury. Patterns in which these patients progress to death remain poorly characterized. We hypothesized that burn nonsurvivors will follow distinct temporal distributions and patterns of decline, parallel to the trimodality of deaths previously described for trauma. METHODS: We retrospectively identified all adult deaths from 1995 to 2007 in the National Burn Repository database (n = 5,975) and at our regional burn center (n = 237). We stratified patients by age and analyzed injury and death characteristics. We used objective criteria to allocate nonsurvivors to one of four trajectories: early rapid decline, early organ failure, late sudden death, or late-onset decline. RESULTS: The greatest concentration of deaths in both samples and age groups occurred within 72 hours of injury and decreased subsequently with no later mortality peak. Death was most often caused by burn shock within the first week of injury, cardiogenic shock or lung injury in Weeks 1 to 2, and sepsis/multiorgan failure after Week 2. In decreasing frequency, trajectories to death fit the pattern of early rapid decline (58%), early organ failure (20%), late-onset decline (16%), and late sudden death (6%). CONCLUSION: Most burn deaths follow a pattern of early rapid decline or early organ failure manifested by death or critical illness within several days of the burn. These findings indicate that more than three quarters of burn deaths are attributable to failure or significant decompensation beginning in the resuscitation phase. Sporadic deaths later in hospitalization are uncommon. Despite significant advances in burn resuscitation, our data indicate that ongoing efforts to mitigate deaths in modern burn care should still focus on care improvements in the resuscitation phase. LEVEL OF EVIDENCE: Epidemiologic study, level III. Language: en

Despite many advances in modern burn care, deaths still occur in the burn intensive care unit. For patients with severe burns, providers may advocate to withdraw life support early during hospitalization when the extent of injury makes survival highly unlikely or when the patient's condition deteriorates during resuscitation. Our regional burn center has implemented a stepwise withdrawal protocol since 2001 in an effort to standardize symptoms palliation at the end of life. In this study, the authors evaluated the frequency of early withdrawal and the protocol impact on end-of-life processes of care in burn patients who died within 72 hours of hospitalization. A 13-year review of all burn patients aged ≥18 years admitted to our burn center to identify all patients who died within 72 hours of hospitalization was performed. Patients were dichotomized to the periods before (1995 to mid-2001) and after implementation of standardized withdrawal protocol (mid-2001 to 2007). Descriptive analyses were performed to compare end-of-life care processes between the two periods. A total of 4374 adult patients with acute burns were admitted during the 13-year study period, of which 252 (6%) died during hospitalization. Of the patients who died within 72 hours, 106 (84%) had withdrawal of life support compared with 20 (16%) who died with ongoing life support. Higher mean TBSA distinguished patients who died by withdrawal (61 vs 48%, P = .06). Since mid-2001, all 61 patients who had life support withdrawn were by protocol. Implementation of the protocol has led to more frequent use of opioid infusion (98 vs 87%, P = .07) and benzodiazepine infusion (95 vs 49%, P < .01), without hastening time to death (median 5.0 vs 5.5 hours, P = .70). The large majority of early burn deaths at our regional center occur via withdrawal of life support. Implementation of a protocolized withdrawal has resulted in more consistent provision of analgesia and sedation without hastening death. Burn centers should consider using a protocol for withdrawal of life support to improve consistency in end-of-life symptoms palliation.

Process planning for assembly requires a computerized representation and analysis of assembled products. In order to recommend a good sequence of assembly operations, the process planner needs to generate all such feasible sequences. This paper presents a methodology to consistently generate all feasible asssembly sequences with consideration for the various combinations of subassembly operations. The methodology is demonstrated on a real product. A practical method to reduce the number of feasible combinations generated is also demonstrated.

Severe burn injury results in a systemic inflammatory response that leads to increased capillary permeability and fluid leak into the interstitium. This global systemic capillary leak can be attributed, at least in part, to inflammatory mediators produced as a result of cellular injury. Plasma exchange has been used in the management of a number of illnesses with a significant inflammatory component, and, therefore, may have a role in the early management of burn injury. The purpose of this study was to review our institutional experience using plasma exchange in the management of severe burn injury. We performed a retrospective review of all patients receiving plasma exchange at our burn center between 2001 and 2005. Data collected included the following: burn size, presence of inhalation injury, resuscitation fluid received, urine output, lactate levels, base deficit levels, and hematocrit before and after the exchange procedure. A total of 37 patients underwent plasma exchange during the 5-year study period and seven patients underwent two plasma exchange treatments. Average TBSA burned was 48.6% (range 18-82) and 73% of patients sustained an inhalation injury. After plasma exchange, hourly fluid volume received significantly decreased (P < .05) and base deficit, lactate, and hematocrit levels significantly improved. Plasma exchange in the early resuscitation period was associated with decreased fluid administration, as well as increased urine output in the period during and immediately after the procedure. These data suggest that plasma exchange may provide a useful tool in the management of severe burn injury.

A generalized resource constrained project scheduling model is developed. In addition to incorporating common generalizations to the resource constrained project scheduling problem, this model can also handle any of the major scheduling objectives, alternative activity completion modes, and the simultaneous scheduling of multiple projects. Furthermore, this approach makes the general project scheduling problem amenable to solution by commercially available mixed integer/linear programming software. The central concept is the split of activities and the allocation of different resource usage rates. Numerical examples are given to illustrate the approach and its advantages.

Improvements in outcomes for older adults sustaining burn injuries have lagged far behind those of younger patients. As this segment of the population grows, there has been an increasing interest in better understanding the epidemiology and outcomes of injury in older adults. The National Burn Repository (NBR) provides a unique opportunity to examine burn injuries on a national level. We aimed to characterize specific injury and outcome trends in older adult with burns through analysis of the NBR. We examined the records of all patients in the NBR aged 55 and older. To characterize age effects on injury and outcomes, patients were stratified into three age categories: 55 to 64 years, 65 to 74 years, and 75 years and older. Baseline characteristics, details of hospital treatment, mortality, and disposition were compared among these three age groups using chi or analysis of variance. Logistic regression analysis was performed to assess the impact of age on burn mortality. A total of 180,401 patient records were available from 1991 to 2005, of which 23,180 (14%) met age inclusion criteria. Mean burn size (9.6% TBSA) and percent with inhalation injury (11.3%) did not markedly differ by age. Men predominated overall (ratio 1.4:1), although women (4290) outnumbered men (3439) in the oldest age category. Length of stay per TBSA and median hospital charges increased with increasing age category, suggesting higher resource consumption with aging. Mean number of operations per patient, however, decreased with age. Mortality rates and discharge to nonindependent status increased with age. By logistic regression, the adjusted odds ratio for mortality was 2.3 (95% CI 2.1-2.7) in the 65 to 74 age group, and 5.4 (95% CI 4.8-6.1) in the oldest group when compared with the 55 to 64 age group. Mortality rates decreased significantly after 2001 across all age groups. This analysis demonstrates age-dependent differences in resource utilization and mortality risk within the older burn population and highlights the need for a national research agenda focused on management practices and outcomes in older adult with burns.

Modern burn care is a resource intensive endeavor requiring specialized equipment, personnel, and facilities in order to provide optimum care. The costs associated with burn injury to both patients and society as a whole can be multifaceted and large. The purpose of this study was to evaluate the association between hospital costs, patient characteristics, and injury factors in a cohort of pediatric patients admitted to a regional burn center. We performed a review of the hospital charges accrued by pediatric patients (age

SUMMARY The part-period balancing lot-sizing algorithm is modified to use fuzzy data for the single-stage lot-sizing problem. Triangular fuzzy numbers are used to represent uncertainty in the master production schedule. This paper shows that uncertain demand can be easily incorporated into the part-period balancing lot-sizing algorithm and that a fuzzy master production schedule can be used to determine production lot sizes. A detailed example is presented to illustrate the technique.

Returning to school is an important indicator of functional aptitude and emotional adjustment in school-aged patients after burn injury. Only two reports in the burn literature provide objective data on time to school re-entry. However, these analyses did not address the impact of patient and burn injury characteristics on time to return to school. The purpose of this study was to determine the time for school re-entry and to identify the factors associated with re-entry time in a cohort of burned children treated at our burn center. We performed a retrospective review of all school age children treated at our burn center from 1997 to 2003 who were entered into a federally funded longitudinal research database for patients with severe burn injury. Time to school re-entry after discharge was calculated for each patient, and multivariate regression was used to identify the factors associated with longer time to return to school. A total of 64 patients were included in this study. The average time to school re-entry was 10.5 days (range, 0-40) and the median time was 7.5 days. Gender (male), age, and length of hospital stay were significantly associated (P < .05) with longer time to return to school. The average time to school return is quite short. Further studies are needed to increase understanding of the factors influencing longer time to re-entry and also to examine children's experiences upon re-entry.

The U.S. Clean Air Act (CAA) explicitly guarantees the protection of sensitive human subpopulations from adverse health effects associated with air pollution exposure. Identified subpopulations, such as asthmatics, may carry multiple genetic susceptibilities to disease onset and progression and thus qualify for special protection under the CAA. Scientific advances accelerated as a result of the ground-breaking Human Genome Project enable the quantification of genetic information that underlies such human variability in susceptibility and the cellular mechanisms of disease. In epidemiology and regulatory toxicology, genetic information can more clearly elucidate human susceptibility essential to risk assessment, such as in support of air quality regulation. In an effort to encourage the incorporation of genomic information in regulation, the U.S. Environmental Protection Agency (EPA) has issued an Interim Policy on Genomics. Additional research strategy and policy documents from the National Academy of Science, the U.S. EPA, and the U.S. Department of Health and Human Services further promote the expansion of asthma genetics research for human health risk assessment. Through a review of these government documents, we find opportunities for the inclusion of genetic information in the regulation of air pollutants. In addition, we identify sources of information in recent scientific research on asthma genetics relevant to regulatory standard setting. We conclude with recommendations on how to integrate these approaches for the improvement of regulatory health science and the prerequisites for inclusion of genetic information in decision making.

The Working Group on Emergency Mass Critical Care was convened by the Center for Biosecurity of the University of Pittsburgh Medical Center and the Society of Critical Care Medicine to provide recommendations to hospital and clinical leaders regarding the delivery of critical care services in the wake of a bioterrorist attack resulting in hundreds or thousands of critically ill patients. In these conditions, traditional hospital and clinical care standards in general, and critical care standards in particular, likely could no longer be maintained, and clinical guidelines for U.S. hospitals facing these situations have not been developed. The Working Group offers recommendations for this situation.

Atlantic Storm was a tabletop exercise simulating a series of bioterrorism attacks on the transatlantic community. The exercise occurred on January 14, 2005, in Washington, DC, and was organized and convened by the Center for Biosecurity of UPMC, the Center for Transatlantic Relations of Johns Hopkins University, and the Transatlantic Biosecurity Network. Atlantic Storm portrayed a summit meeting of presidents, prime ministers, and other international leaders from both sides of the Atlantic Ocean in which they responded to a campaign of bioterrorist attacks in several countries. The summit principals, who were all current or former senior government leaders, were challenged to address issues such as attaining situational awareness in the wake of a bioattack, coping with scarcity of critical medical resources such as vaccine, deciding how to manage the movement of people across borders, and communicating with their publics. Atlantic Storm illustrated that much might be done in advance to minimize the illness and death, as well as the social, economic, and political disruption, that could be caused by an international epidemic, be it natural or the result of a bioterrorist attack. These lessons are especially timely given the growing concerns over the possibility of an avian influenza pandemic that would require an international response. However, international leaders cannot create the necessary response systems in the midst of a crisis. Medical, public health, and diplomatic response systems and critical medical resources (e.g., medicines and vaccines) must be in place before a bioattack occurs or a pandemic emerges.

To study factors related to breast cosmetic outcome in patients treated with an interstitial implant as part of breast-conservation therapy.One hundred fifty-six patients with stage I or II breast carcinoma who received 50 Gy of external-beam irradiation followed by a 20-Gy interstitial boost were examined. The dose homogeneity index (DHI) was calculated for each evaluable implant and was examined in light of other patient-, treatment-, and tumor-related variables previously demonstrated to affect cosmesis.Of the variables examined, both the DHI (P = .021) and the total excision volume (P = .019) were significantly related to cosmetic outcome (excellent vs less than excellent) in a univariate model. In the multivariate analysis, only the total excision volume remained significant (P = .032). The mean total excision volume +/- SD in patients with excellent cosmetic outcome (81.8 cm3 +/- 84.0) was significantly less than that in patients with less than excellent cosmetic outcome (120 cm3 +/- 84). The probability of excellent cosmetic outcome linearly increased with an increase in DHI. The mean DHI was 0.74 +/- 0.12 for the cases with excellent cosmetic outcome and 0.68 +/- 0.10 for those with less than excellent cosmetic outcome.To achieve optimal cosmesis, DHI should be maximized. The volume of tissue removed, however, remains the most significant determinant.

Purpose: Margin assessment is commonly used as a guide to the relative aggressiveness of therapy for breast conserving treatment (BCT), though its value as a predictor of the presence, type, or extent of residual tumor has not been conclusively studied. Controversy continues to exist as to what constitutes a margin that is "positive," "close,", or "negative." We attempt to address these issues through an analysis of re-excision specimens. Methods and Materials: As part of an institutional prospective practice approach for BCT, 265 cases with AJCC Stage III carcinoma with an initial excision margin that was ≤2 mmor indetermine were subjected to re-excision. The probability of residual tumor (+RE) was evaluated with respect to tumor size, histopathologic subtype, relative closeness of the measured margin, the extent of margin positivity graded as focal, minimal, moderate, or extensive, and the extent of specimen processing as reflected in the number of cut sections per specimen volume (S:V ratio). Teh amount of residual tumor was graded as microscopic, small, medium, or large. The histopathologic subtype of tumor in the re-excision specimen was classified as having an invasive component (ICa) or pure DCIS (DCIS). Results: The primary excision margin was positive, >0≤1 mm, 1.2–2 mm, and indeterminate in 60%, 18%, 5%, and 17%, respectively. The predominant histopathologies in the initial excision specimens were invasvie ductal (IDC) (50%) and tumors with an extensive intraductal component (EIC) 43%). The histopathology of the initial excision specimen was highly predictive of the histopathology of tumor found on re-excision, as residual DCIS was found in 60% of +RE specimens with initial histopathology of EIC compared to 26% for IDC ( p = 0.001). Neither the extent of margin positivity nor the extent of tumor in the re-excision were significantly related to the initial histopathologic subtype; however, a +RE was seen in 59% of EIC, 43% of IDC, and 32% of invasive lobular ILC case ( p = 0.01). The extent of margin positivity was siginificantly related to the size of the tumor such that tumor size ≤ 20 mm was associated with a greater probability of focal or minimal margin involvement. Positive margins graded as focal, minimal, moderate/extensive were associated with a +RE in 26%, 58%, and 84%, respectively ( p = 0.001). Further, the extent of positivity was significantly correlated with the extent of residual tumor such that focal/minimal positivity was more commonly associated with micro/small +RE, whereas moderate/extensive positivity was associated with medium/large +RE. When the closest margin of the initial excision specimen was positive, >0≤1 mm, or 1.1–2 mm, a +RE was foudn in 56%, 41%, and 17%, respectively ( p = 0.01) but did not correlate with the amount of residual tumor. The extent of specimen processing as reflected in the S:V ratio did not correlate with the probability of defining a measured margin as positive nor the probability of a +RE. IN a univariate model, the extent of tumor in the re-excision and the histologic type of tumor in the re-excision were significantly association with margin status adn initial histopathology, respectively. The probability of finding a +RE, based on a multivariate model, was associated with the closeness and extent of margin involvement and initial histopathology of an EIC. Conclusion: The relative closeness of tumor to the specimen and the of margin positivity are predictive for residual tumor, though with an error consistent with its limitations as a sampling procedure. The histopathology of tumor in the initial excision is predictive of the type of residual tumor and the extent of margin positivity was correlated with the amount of residual tumor.

Context The delivery of burn care is a resource-intensive endeavor that requires specialized personnel and equipment. The optimal geographic distribution of burn centers has long been debated; however, the current distribution of centers relative to geographic area and population is unknown. Objective To estimate the proportion of the US population living within 1 and 2 hours by rotary air transport (helicopter) or ground transport of a burn care facility. Design and Setting A cross-sectional analysis of geographic access to US burn centers utilizing the 2000 US census, road and speed limit data, the Atlas and Database of Air Medical Services database, and the 2008 American Burn Association Directory. Main Outcome Measure The proportion of state, regional, and national population living within 1 and 2 hours by air transport or ground transport of a burn care facility. Results In 2008, there were 128 self-reported burn centers in the United States including 51 American Burn Association–verified centers. An estimated 25.1% and 46.3% of the US population live within 1 and 2 hours by ground transport, respectively, of a verified burn center. By air, 53.9% and 79.0% of the population live within 1 and 2 hours, respectively, of a verified center. There was significant regional variation in access to verified burn centers by both ground and rotary air transport. The greatest proportion of the population with access was highest in the northeast region and lowest in the southern United States. Conclusion Nearly 80% of the US population lives within 2 hours by ground or rotary air transport of a verified burn center; however, there is both state and regional variation in geographic access to these centers.

To evaluate the relative utility of interstitial implant as a technique for tumor bed dose escalation and assess technical factors related to outcome.From 1982-1994, a prospectively applied institutional policy of margin-directed boost dose escalation to the tumor bed was followed whereby interstitial implantation was commonly employed for a final margin status (FMS)or = 2 mm. There were 509 treated breasts, of which 127 received an implant boost. For purposes of comparison, cases were broadly classed as "implant" (all FMSor = 2 mm) and "nonimplant" (FMSor = 2 mm or FMS2 mm). The implant target volume was determined at completion of whole breast irradiation by clinical assessment. All implants were constructed in accordance with a preplanning algorithm designed to maximize dose homogeneity within a prescription isodose goal of 0.50 Gy/h for 40 h. Local control and cosmetic outcome were evaluated with respect to extent of tumor, histopathology, FMS, extent of surgery, and systemic adjuvant therapy. Implant quality was assessed using four calculated parameters: strand separation quotient (SSQ), planar separation quotient (PSQ), global separation quotient (GSQ), and dose homogeneity index (DHI). The mean implant volume was 48.3 +/- 20 cc, the mean prescribed dose rate was 0.46 +/- 0.08 Gy/h, and the mean total implant dose was 19.94 +/- 1.52 Gy.Cosmetic outcome was good/excellent in 90% of implant and 83% of all nonimplant cases, which was not statistically different. Cosmesis was significantly superior with implant when compared to nonimplant cases receiving an external boost of 20 Gy. Logistic regression analyses of implant cases revealed that reexcision volume and decreased DHI were associated with adverse cosmesis. There were 10 local failures in the implanted patients (4 within the prescribed isodose volume, 5 at the periphery, and 1 elsewhere in the breast). The local failure rate at 5 and 7 years in the implanted group was 3.9 and 9.0%, respectively, compared to nonimplant cases with a marginor = 2 mm of 3.2 and 3.2%, respectively. These differences were not significant. The crude local failure rate in patients with an associated DCIS component was 12% a compared to 3% in patients with pure invasive histology (p = 0.06). A proportional hazards survival model revealed a significant association of local failure with the performance of a reexcision and young age.We conclude that interstitial implant boost for breast conserving irradiation is associated with cosmesis that is superior than the same nominal dose of external beam boost, although this is highly dependent upon the technical quality of the source position and the relative uniformity of dose deposition. Breast implantation results in a rate of local control no better than dose-matched external beam boost in patients with a final marginor = 2 mm. Local control with implantation might be further enhanced by increasing implant volume and/or improved target localization.