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Autologous skin grafting has permitted survival and restoration of function in burn injuries of ever larger total body surface area (TBSA) sizes. However, the goal of replacing “like with like” skin structures is often impossible because full-thickness donor harvesting requires primary closure at the donor site for it to heal. Split-thickness skin grafting (STSG), on the other hand, only harvests part of the dermis at the donor site, allowing it to re-epithelialize on its own. The development of the first dermal regenerative template (DRT) in the late 1970s represented a major advance in tissue engineering that addresses the issue of insufficient dermal replacement when STSGs are applied to the full-thickness defect. This review aims to provide an overview of currently available DRTs in burn management from a clinician’s perspective. It focuses on the main strengths and pitfalls of each product and provides clinical pearls based on clinical experience and evidence.

Background The Choosing Wisely Campaign was launched in 2012 and has been applied to a broad spectrum of disciplines in almost thirty countries, with the objective of reducing unnecessary or potentially harmful investigations and procedures, thus limiting costs and improving outcomes. In Canada, patients with burn injuries are usually initially assessed by primary care and emergency providers, while plastic or general surgeons provide ongoing management. We sought to develop a series of Choosing Wisely statements for burn care to guide these practitioners and inform suitable, cost-effective investigations and treatment choices. Methods The Choosing Wisely Canada list for Burns was developed by members of the Canadian Special Interest Group of the American Burn Association. Eleven recommendations were generated from an initial list of 29 statements using a modified Delphi process and SurveyMonkey™. Results Recommendations included statements on avoidance of prophylactic antibiotics, restriction of blood products, use of adjunctive analgesic medications, monitoring and titration of opioid analgesics, and minimizing ‘routine’ bloodwork, microbiology or radiological investigations. Conclusions The Choosing Wisely recommendations aim to encourage greater discussion between those involved in burn care, other health care professionals, and their patients, with a view to reduce the cost and adverse effects associated with unnecessary therapeutic and diagnostic procedures, while still maintaining high standards of evidence-based burn care.

Key Points Question How common is nonfatal self-injury (NFSI) after a cancer diagnosis, and what are the associated risk factors? Findings In this cohort study of 806 910 adults with cancer, 0.3% of the population had an NFSI event within 5 years of diagnosis. Age, history of severe psychiatric illness, and prior self-injury were the factors most strongly associated with NFSI. Meaning These findings suggest that age, prior severe psychiatric illness, and prior self-injury could be used to identify patients with cancer at risk of NFSI events., This cohort study examines the risk of nonfatal self-injury following a cancer diagnosis., Importance Psychological distress is a key component of patient-centered cancer care. While a greater risk of suicide among patients with cancer has been reported, more frequent consequences of distress, including nonfatal self-injury (NFSI), remain unknown. Objective To examine the risk of NFSI after a cancer diagnosis. Design, Setting, and Participants This population-based retrospective cohort study used linked administrative databases to identify adults diagnosed with cancer between 2007 and 2019 in Ontario, Canada. Exposures Demographic and clinical factors. Main Outcomes and Measures Cumulative incidence of NFSI, defined as emergency department presentation of self-injury, was computed, accounting for the competing risk of death from all causes. Factors associated with NFSI were assessed using multivariable Fine and Gray models. Results In total, 806 910 patients met inclusion criteria. The mean (SD) age was 65.7 (14.3) years, and 405 161 patients (50.2%) were men. Overall, 2482 (0.3%) had NFSI and 182 (

Introduction Hydroxycobalamin (HC) is administered to patients with suspected hydrogen cyanide poisoning. Some reports suggest that this practice may be associated with acute kidney injury (AKI). We aimed to evaluate the association between HC administration and AKI after burn injury. Methods We conducted a retrospective matched cohort study. All adults admitted to a regional ABA-verified burn center within 24 hours of injury between 2015-2019 with >10% total body surface area (TBSA) flame burn injury were reviewed. We excluded patients who were palliated within 48 hours of admission, and those with pre-existing renal disease. Patients who received HC, either pre-hospital, in the emergency department, or the burn center, were matched on age (+/-2 years) and %TBSA (+/-5%) to up to 5 patients who did not receive HC. Rates of AKI within 7 days of admission, as defined by KDIGO criteria, were then compared. Secondary outcomes included receipt of renal replacement therapy, death, ventilator days, and discharge disposition. Results We identified 10 patients who received HC; these patients were matched to 42 patients who did not receive HC. The median age of the HC group was 57 (IQR 43-66), compared to 65 in the non-HC group (IQR 57-65) (p= 0.98). The median %TBSA burn and %TBSA full thickness burn in the HC group and control was 16.5 (14-19) vs 13.5 (11-18) respectively (p= 0.22) and 3.5 vs 3.5 (0-9.5) respectively (p= 0.93). The incidence of inhalation injury in the HC group (n=8, 80%) was significantly higher than in the non-HC group (n=7, 17%)(p< 0.001). All HC patients were intubated within 24 hours of admission vs. only 48% of controls (p=0.003). The HC group also had significantly higher median SOFA scores on admission (9.5 vs 4, p< 0.001) and had a significantly higher admission creatinine [1.08 (0.95-1.26) vs 0.86 (0.71-1.02) mg/dl), p= 0.02]. The median 24-hour crystalloid fluid administered was 5911 mL/kg/%TBSA in the HC group vs 2774 mL/kg/%TBSA burn in controls (p= 0.004). All patients in the HC group developed AKI (n=10, 100%), compared to 64% (n=27) of non-HC patients (p=0.03). There was no significant difference in rates of death (20% vs 10%, p=0.35), Renal Replacement Therapy (20% vs 7%, p=0.21), discharge disposition, or ventilator days between groups. Conclusions We identified a small number of patients who received HC over a 5-year period at our burn center. There was an association between HC administration and development of AKI, but there were no differences in mortality, RRT, or ventilator days. HC administration is rare, and our data suggest that the sickest burn injured patients receive it. Larger studies are required to determine if HC administration is associated with AKI, or whether the increased rate of AKI in our study reflects illness severity.

Two experiments (Total N = 393) demonstrated that disparagement humor can trigger a social identity threat for members of the targeted group resulting in perceptions of a diminished possible self a...

To estimate long-term mortality following major burn injury compared with matched controls.The effect of sustaining a major burn injury on long-term life expectancy is poorly understood.Using health administrative data, all adults who survived to discharge after major burn injury between 2003 and 2013 were matched to between 1 and 5 uninjured controls on age, sex, and the extent of both physical and psychological comorbidity. To account for socioeconomic factors such as residential instability and material deprivation, we also matched on marginalization index. The primary outcome was 5-year all-cause mortality, and all patients were followed until death or March 31, 2014. Cumulative mortality estimates were estimated using the Kaplan-Meier method. Cox proportional hazards modeling was used to estimate the association of burn injury with mortality.In total, 1965 burn survivors of mean age 44 (standard deviation 17) years with median total body surface area burn of 15% [interquartile range (IQR) 5-15] were matched to 8671 controls and followed for a median 5 (IQR 2.5-8) years. Five-year mortality was significantly greater among burn survivors (11 vs 4%, P0.001). The hazard ratio was greatest during the first year (4.15, 95% CI 3.17-5.42), and declined each year thereafter, reaching 1.65 (95% CI 1.02-2.67) in the fifth year after discharge. Burn survivors had increased mortality related to trauma (mortality rate ratio, MRR 9.8, 95% CI 5-19) and mental illness (MRR 9.1, 95% CI 4-23).Burn survivors have a significantly higher rate of long-term mortality than matched controls, particularly related to trauma and mental illness. Burn follow-up should be focused on injury prevention, mental healthcare, and detection and treatment of new disease.

Introduction The loss of income from injury, additional health care expenses, and inability to return work can lead to unsatisfactory outcomes. Community level disadvantage (e.g., low high school completion, low home ownership, low income) are more common among minority groups. We hypothesized community level disadvantage would negatively impact the ability to return to work after burn injury. This could serve to identify patients who need focused social, vocational, and financial support during rehabilitation. Methods Data from adult participants in a large multicenter database from 1998-2021 were linked by zip-code to three multi-domain community level-indices: i) Distressed Communities Index, ii) Social Vulnerabilities Index (SVI), iii) Social Deprivation Index (SDI). Cohort characteristics, the distribution of each index within cohort, and days to return to work were described. Fit and strength of association between the indices and return to work was assessed with multi-level logistic regression models. A non-responder analysis examining demographic and clinical differences between was performed using Chi-square tests and Wilcoxon rank sum tests to understand potential bias in the findings. Results A total of 1960 participants provided both zip code and employment data 6 months after injury. 75% of participants were male. Mean age was 39. Race/Ethnicity Data: 81.4% identified as White, 11% Black, and 7% as “other” race; 84% of the participants as non-Hispanic or Latino. Median burn size was 20% TBSA (IQR 0.1-95.0), and length of hospitalization was 30 days (IQR 0-379). Of the community indices tested, both DCI and SVI were associated with return to work with DCI having the strongest association with return to work after injury, irrespective of indices. However, when DCI and SVI were included in the model to represent community disadvantage, the impact of race on return to work was less. Participants who did not provide employment information were younger, sustained larger burn sizes, and had longer LOS compared to those who did. Conclusions DCI and SVI are associated with return to work after burn injury and can be used to focus limited social, vocational, and financial services. Minoritized participants were less likely to return to work but they live in communities with greater disadvantage (e.g. fewer employment opportunities), which highlights the public health impacts of structural racism.

Introduction Pain is a common and often debilitating sequelae of a significant burn injury. Clinicians and researchers need clinically valid, reliable pain measures to guide treatment decisions and to provide evidence for study protocol development. Pain rating scores that represent mild, moderate, and severe pain in the burn survivor population have not been established. The aim of this study was to determine the numerical pain intensity rating scores that best represent mild, moderate, and severe pain in adult burn survivors. Methods Average pain intensity visual analog scale (VAS; 0–10) and customized PROMIS pain interference short form was administered to adult burn survivors (age ≥18) treated at a regional burn center at hospital discharge and at 6, 12, and 24-months postburn. To identify the optimal VAS scores for mild, moderate, and severe pain we computed F values and Bayesian Information Criterion (BIC) statistics associated with multiple ANOVA comparisons for mean pain interference scores by various VAS pain intensity cut points. Six possible cut points (CP) were compared: CP 3,6; CP 3,7; CP 4,6; CP 4,7; CP 2,5; and CP 3,5. For example, CP 3,6 refers to pain categorized as mild (0–3), moderate (4–6), and severe (7–10). Optimal cutoffs were those with the highest ANOVA F statistics. Models with similar F statistics were compared using changes in BIC. Results 178 participants (85% white, 65% male, mean age of 46 years) with pain intensity and interference scores at one or more timepoints comprised the study sample. The optimal classification for mild, moderate, and severe pain at baseline and 12-months was CP 2,5. Although CP 3,6 had the highest F value at 6-months, there was not strong evidence to support CP 3,6 over CP 2,5 (BIC difference: 2.9); similarly, CP 3,7 had the highest value at 24-months, but the BIC difference over CP 2,5 was minimal (2.2). Conclusions We recommend that visual analog pain intensity scores for adult burn survivors be categorized as mild (0–2), moderate (3–5), and severe (6–10). These findings advance our understanding regarding the meaning of pain intensity ratings following a burn injury and provide an objective definition for clinical management, quality improvement, and pain research.

Introduction Individual- and community-level socioeconomic disparities impact overall health and injury incidence, severity, and outcomes. However, the impact of community-level socioeconomic disparities on recovery after burn injury is unknown. We aimed to characterize the association between community-level socioeconomic disparities and health-related quality of life (HRQL) after burn injury. These findings might inform rehabilitation service delivery and policy making at administrative levels. Methods Participants with the NIDILRR Burn Model System who were ≥14 years with a zip code were included. Sociodemographic and injury characteristics and 12-item Short Form Health Survey (SF-12) and Veterans RAND (VR-12) physical (PCS) and mental (MCS) component summary scores 6 months after injury were extracted. Data were deterministically linked by zip code to the Distressed Communities Index (DCI), which combines seven census-derived metrics into a single indicator of economic well-being that ranges from 0 (lowest distress) to 100 (highest distress). Multilevel linear regression models estimated the association between DCI and HRQL. Results The 342 participants were mostly male (239, 69%) had a median age of 48 years (IQR 33–57) and sustained a median burn size of 10% TBSA (IQR 3–28%). More than one-third of participants (117, 34%) lived in a neighborhood within the two most distressed quintiles. After adjusting for age, race/ethnicity, and pre-injury HRQL, increasing neighborhood distress was negatively associated with PCS (ß-0.05, SE 0.02, p=0.01). Age and pre-injury PCS were also significantly associated with 6-month PCS. There was no association between neighborhood distress and 6-month MCS. However, pre-injury MCS was significantly associated with 6-month MCS (0.56, SE 0.07, p< 0.001). Conclusions Neighborhood distress is associated with lower PCS after burn injury but is not associated with MCS. Regardless of neighborhood distress, pre-injury HRQL is significantly associated with both PCS and MCS during recovery.

Introduction Ongoing increases in the prevalence of substance misuse among burn-injured patients necessitate a contemporary analysis of the association between substance misuse and clinical outcomes in burn-injured adults. Methods We conducted a retrospective cohort study of 1199 patients admitted to a regional burn center. History of substance misuse was derived from a prospective clinical registry and categorized as alcohol, illicit drug, or both. The primary outcome was hospital length of stay; association of substance misuse and inpatient complications were secondary outcomes. Multivariable logistic regression was used to model the association between categories of substance misuse and each outcome, adjusting for patient and injury characteristics. Results The incidence of substance misuse was 34% overall. After adjustment for patient and injury characteristics, drug misuse was associated with a significantly longer length of stay (RR 1.12; 95% CI 1.00–1.25), as was alcohol misuse (RR 1.32; 95% CI 1.14–1.52), and drug/alcohol misuse (RR 1.34; 95% CI 1.16–1.56). Drug/alcohol misuse was associated with significantly higher rates of bacteremia (OR 3.84; 95% CI 1.83–8.04) and sepsis (OR 2.50; CI 1.13–5.53). Conclusions A history of substance misuse is associated with an increased risk of inpatient complications and longer hospital stay. Providers should be cognizant of increased complications in this cohort with a view to improving outcomes.

Burn-related mortality has decreased significantly over the past several decades. Although often attributed in part to regionalization of burn care, this has not been evaluated at the population level.We conducted a retrospective, population-based cohort study of all patients with 20% or higher total body surface area burn injury in Ontario, Canada. Adult (≥16 years) patients injured between 2003 and 2013 were included. Deaths in the emergency department were excluded. Logistic generalized estimating equations were used to estimate risk-adjusted 30-day mortality. Mortality trends were compared at burn and nonburn centers.Seven hundred seventy-two patients were identified at 84 centers (2 burn, 82 nonburn). Patients were 74% (n = 570) male, of median age 46 (interquartile range [IQR], 35-60) years and median total body surface area 35% (IQR, 25-45). Mortality at 30 days was 19% (n = 149). The proportion of patients treated at a burn center increased from 57% to 71% between 2003 and 2013 (p = 0.07). Average risk-adjusted 30-day mortality rates decreased over time; there were significantly reduced odds of death in 2010 to 2013 compared with 2003 to 2006 (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.25-0.61). Burn centers exhibited significantly reduced mortality from 2003-2006 to 2010-2013 (OR, 0.36; 95% CI, 0.34-0.38) compared with nonburn centers (OR, 0.41; 95% CI, 0.13-1.24).Mortality rates have decreased over time; significant improvements have occurred at burn centers, whereas mortality rates at nonburn centers vary widely. A high proportion of patients continue to receive care outside of burn centers. These data suggest that there are further opportunities to regionalize burn care and in so doing, potentially lower burn-related mortality.Epidemiological study, level III; Therapy, level IV.

Pulmonary embolism (PE) is a leading cause of delayed mortality in patients with severe injury. While low-molecular-weight heparin (LMWH) is often favored over unfractionated heparin (UH) for thromboprophylaxis, evidence is lacking to demonstrate an effect on the occurrence of PE. This study compared the effectiveness of LMWH versus UH to prevent PE in patients following major trauma.Data for adults with severe injury who received thromboprophylaxis with LMWH or UH were derived from the American College of Surgeons Trauma Quality Improvement Program (2012-2015). Patients who died or were discharged within 5 days were excluded. Rates of PE were compared between propensity-matched LMWH and UH groups. Subgroup analyses included patients with blunt multisystem injury, penetrating truncal injury, shock, severe traumatic brain injury, and isolated orthopedic injury. A center-level analysis was performed to determine if practices with respect to choice of prophylaxis type influence hospital PE rates.We identified 153,474 patients at 217 trauma centers who received thromboprophylaxis with LMWH or UH. Low-molecular-weight heparin was given in 74% of patients. Pulmonary embolism occurred in 1.8%. Propensity score matching yielded a well-balanced cohort of 75,920 patients. After matching, LMWH was associated with a significantly lower rate of PE compared with UH (1.4% vs. 2.4%; odds ratio, 0.56; 95% confidence interval, 0.50-0.63). This finding was consistent across injury subgroups. Trauma centers in the highest quartile of LMWH utilization (median LMWH use, 95%) reported significantly fewer PE compared with centers in the lowest quartile (median LMWH use, 39%; 1.2% vs. 2.0%; odds ratio, 0.59; 95% confidence interval, 0.48-0.74).Thromboprophylaxis with LMWH (vs. UH) was associated with significantly lower risk of PE. Trauma centers favoring LMWH-based prophylaxis strategies reported lower rates of PE. Low-molecular-weight heparin should be the anticoagulant agent of choice for prevention of PE in patients with major trauma.Therapeutic study, level III.

Introduction Previous data suggest that disparities exist in access to inpatient rehabilitation following burn injury. We aimed to characterize the association between patient race/ethnicity and discharge disposition across multiple centers. Methods Data were derived from the prospectively maintained Burn Model Systems national database. All participants admitted to one of five participating centers between 1994 and 2019, who survived to discharge with a known disposition, were included. The relationship between patient characteristics, injury factors and discharge to home, a skilled nursing facility (SNF), or inpatient rehabilitation was modeled using multinomial generalized estimating equations. Pre-specified stratified analyses were conducted to examine effect modification. Results We identified 4395 participants who met inclusion criteria. Participants were 74% White non-Hispanic (n=3269), 18% Black non-Hispanic (n=812), 3% Hispanic (n=122), 0.5% Asian (n=24), and 4% Other (n=168). Most were aged 18–64 years (68%, n=2998). Overall, 79% (n=3585) of participants were discharged home, 12% to inpatient rehabilitation (n=534), and 6% to SNF (n=276). After adjustment for patient characteristics and injury factors, there were no differences in discharge destination by race/ethnicity. However, subgroup analyses demonstrated effect modification by both center and burn size. At 2 centers, Black participants were significantly more likely to be discharged to SNF or inpatient rehabilitation (Center 1 OR 1.98, 95% CI 1.02–3.85; Center 2 OR 2.36, 95% CI 1.07–5.19). Similarly, among all participants with >20% TBSA, Black participants were more likely to be discharged to SNF or inpatient rehabilitation (OR 1.38, 95% CI 1.06–1.81). Across all groups, having insurance was associated with discharge to SNF or inpatient rehabilitation (OR 1.68, 95% CI 1.21–2.33). Conclusions Although no overall difference in discharge destination by race was identified, stratified analyses indicate disparities in discharge disposition at the patient and system level. At specific centers, and among those with >20% TBSA injury, Black participants are more likely to be discharged to SNF and inpatient rehabilitation than other ethnic groups. Applicability of Research to Practice Both patient and system level factors are associated with discharge to higher levels of post-discharge care, suggesting that further characterization of these factors is warranted. Such data can inform interventions and policy changes aimed at ensuring equitable access to appropriate post-discharge care.

The goal of population-based research is to answer research questions or hypotheses for a defined population [1]. Population-based research using administrative data can address some of the challenges in longitudinal studies, such as poor follow-up, and recollection bias [2]. Additionally, study findings can be generalizable to the entire population studied, not just a specific cohort. The population is usually defined by geographical boundaries, such as a province, state, and country [3]. However, populations may also be defined by membership in particular health maintenance organizations, such as Kaiser-Permanente Insurance program enrollees in the United States [2]. Such research can involve longitudinal assessment of individuals to assess exposure–outcome relationships and answer questions about individuals from a particular population [2].

Motor vehicle crashes (MVCs) are a leading public health concern. Emergency medical service (EMS) response time is a modifiable, system-level factor with the potential to influence trauma patient survival. The relationship between EMS response time and MVC mortality is unknown.To measure the association between EMS response times and MVC mortality at the population level across US counties.This population-based study included MVC-related deaths in 2268 US counties, representing an estimated population of 239 464 121 people, from January 1, 2013, through December 31, 2015. Data were analyzed from October 1, 2017, through April 30, 2018.The median EMS response time to MVCs within each county (county response time), derived from data collected by the National Emergency Medical Service Information System.The county rate of MVC-related death, calculated using crash fatality data recorded in the Fatality Analysis Reporting System of the National Highway Traffic Safety Administration.During the study period, 2 214 480 ambulance responses to MVCs were identified (median, 229 responses per county [interquartile range (IQR), 73-697 responses per county]) in 2268 US counties. The median county response time was 9 minutes (IQR, 7-11) minutes. Longer response times were significantly associated with higher rates of MVC mortality (≥12 vs7 minutes; mortality rate ratio, 1.46; 95% CI, 1.32-1.61) after adjusting for measures of rurality, on-scene and transport times, access to trauma resources, and traffic safety laws. This finding was consistent in both rural/wilderness and urban/suburban settings, where a significant proportion of MVC fatalities (population attributable fraction: rural/wilderness, 9.9%; urban/suburban, 14.1%) were associated with prolonged response times (defined by the median value, ≥10 minutes and ≥7 minutes, respectively).Among 2268 US counties, longer EMS response times were associated with higher rates of MVC mortality. A significant proportion of MVC-related deaths were associated with prolonged response times in both rural/wilderness and urban/suburban settings. These findings suggest that trauma system-level efforts to address regional disparities in MVC mortality should evaluate EMS response times as a potential contributor.

IMPORTANCE: Adhesive small-bowel obstruction (aSBO) is a potentially chronic, recurring surgical illness. Although guidelines suggest trials of nonoperative management, the long-term association of this approach with recurrence is poorly understood. OBJECTIVE: To compare the incidence of recurrence of aSBO in patients undergoing operative management at their first admission compared with nonoperative management. DESIGN, SETTING, AND PARTICIPANTS: This longitudinal, propensity-matched, retrospective cohort study used health administrative data for the province of Ontario, Canada, for patients treated from April 1, 2005, through March 31, 2014. The study population included adults aged 18 to 80 years who were admitted for their first episode of aSBO. Patients with nonadhesive causes of SBO were excluded. A total of 27 904 patients were included and matched 1:1 by their propensity to undergo surgery. Factors used to calculate propensity included patient age, sex, comorbidity burden, socioeconomic status, and rurality of home residence. Data were analyzed from September 10, 2017, through October 4, 2018. EXPOSURES: Operative vs nonoperative management for aSBO. MAIN OUTCOMES AND MEASURES: The primary outcome was the rate of recurrence of aSBO among those with operative vs nonoperative management. Time-to-event analyses were used to estimate hazard ratios of recurrence while accounting for the competing risk of death. RESULTS: Of 27 904 patients admitted with their first episode of aSBO, 6186 (22.2%) underwent operative management. Mean (SD) patient age was 61.2 (13.6) years, and 51.1% (14 228 of 27 904) were female. Patients undergoing operative management were younger (mean [SD] age, 60.2 [14.3] vs 61.5 [13.4] years) with fewer comorbidities (low burden, 382 [6.2%] vs 912 [4.2%]). After matching, those with operative management had a lower risk of recurrence (13.0% vs 21.3%; hazard ratio, 0.62; 95% CI, 0.56-0.68; P

e18577 Background: Psychological distress is a key construct of patient-centred cancer care. While an increased risk of suicide for cancer patients has been reported, more frequent consequences of distress after a cancer diagnosis, such as non-fatal self-injury (NFSI), remain largely unknown. We examined the risk for NFSI after a cancer diagnosis. Methods: Using linked administrative databases we identified adults diagnosed with cancer between 2007-2019. Cumulative incidence of NFSI, defined as emergency department presentation of self-injury, was computed accounting for the competing-risk of death from all causes. Factors associated with NFSI were assessed using multivariable Fine and Gray models. Results: Of 806,910 included patients, 2,482 had NFSI and 182 died by suicide. 5-year cumulative incidence of NFSI was 0.27% [95%CI 0.25-0.28%]. After adjusting for key confounders, prior severe psychiatric illness whether requiring inpatient care (sub-distribution hazard ratio (sHR) 12.6, [95% CI 10.5-15.2]) or outpatient care (sHR 7.5, 95% CI 6.48-8.84), and prior self-injury (sHR 6.6 [95% CI 5.5-8.0]) were associated with increased risk of NFSI. Young adults (age 18-39) had the highest NFSI rates, relative to individuals >70 (sHR 5.4, [95% CI 4.5-6.5]). The magnitude of association between prior severe psychiatric illness and NFSI was greatest for young adults (interaction term p < 0.01). Certain cancer subsites were also at increased risk, including head and neck (sHR1.52, [95%CI 1.19-1.93]). Conclusions: Patients with cancer have higher incidence of NFSI than suicide after diagnosis. Younger age, prior severe psychiatric illness, and prior self-injury were independently associated with NFSI. These exposures act synergistically, placing young adults with a prior mental health history at greatest risk for NFSI events. Those factors should be used to identify at-risk patients for psycho-social assessment and intervention.

OBJECTIVES: Metabolic alterations after burn injury have been well described in children; however, in adult patients, glucose metabolism and insulin sensitivity are essentially unknown. We sought to characterize metabolic alterations and insulin resistance after burn injury and determine their magnitude and persistence at discharge. DESIGN: Prospective, cohort study. SETTING: Tertiary burn centre. PATIENTS: Nondiabetic adults with an acute burn involving greater than or equal to 20% total body surface area. INTERVENTIONS: An oral glucose tolerance test was administered at discharge. MEASUREMENTS AND MAIN RESULTS: Glucose, insulin, and C-peptide levels were measured to derive surrogate measures of insulin resistance and β-cell function, including quantitative insulin sensitivity check index, homeostasis model assessment of β-cell function, homeostasis model assessment of insulin sensitivity, homeostasis model assessment of insulin resistance, and the composite whole-body insulin sensitivity index. Patients were grouped according to the degree of glucose tolerance: normal glucose tolerance, impaired fasting glucose/impaired glucose tolerance, or diabetes. Forty-five adults, 44 ± 15 years old and with 38% ± 14% total body surface area burned, underwent an oral glucose tolerance test at discharge. Median quantitative insulin sensitivity check index (0.348 [0.332-0.375]) and median homeostasis model assessment of insulin resistance (1.13 [0.69-1.45]) were abnormal, indicating insulin resistance and impaired insulin production at discharge. Two-thirds of patients (n = 28) met criteria for impaired fasting glucose/impaired glucose tolerance or diabetes. CONCLUSIONS: We have demonstrated that burn-injured adults remain hyperglycemic, are insulin resistant, and express defects in insulin secretion at discharge. Patients with lower burn severity (total body surface area, 20-30%) express similar metabolic alterations as patients with larger burns (total body surface area, ≥ 30%). Glucose tolerance testing at discharge offers an opportunity for early identification of burn patients who may be at high risk of prediabetes and diabetes. Our findings demonstrated that two-thirds of burn patients had some degree of glucose intolerance. With this in mind, surveillance of glucose intolerance post discharge should be considered. As hyperglycemia and insulin resistance are associated with poor outcomes, studies should focus on how long these profound alterations persist. Language: en

Background Mental health disorders are prevalent before and after burn injury. However, the impact of burn injury on risk of subsequent mental health disorders is unknown. Study Design We conducted a population-based, self-matched longitudinal cohort study using administrative data in Ontario, Canada between 2003 and 2011. All adults who survived to discharge after major burn injury were included, and all mental health-related emergency department visits were identified. Rate ratios (RRs) for mental health visits in the 3 years after burn, compared with the 3 years before, were estimated using negative binomial generalized estimating equations. Results Among 1,530 patients with major burn injury, mental health visits were common both before (141 per 1,000 person years) and after (154 per 1,000 person years) injury. Mental health visits were most common in the 12 weeks immediately preceding injury. No significant difference in the overall visit rate was observed after burn (RR 0.97; 95% CI 0.78 to 1.20), although among patients with less than 1 pre-injury visit, mental health visits tripled (RR 3.72; 95% CI 2.70 to 5.14). Self-harm emergencies increased 2-fold (RR 1.95; 95% CI 1.15 to 3.33). Conclusions Mental health emergencies are prevalent among burn-injured patients. Although the overall rate of mental health visits is not increased after burn, the rate increases significantly among patients with one or fewer visits pre-injury. Self-harm risk increases significantly after burn injury, underscoring the need for screening and targeted interventions after discharge. An increased rate immediately before burn suggests an opportunity for injury prevention through mental healthcare.

We set out to compare the incidence of bowel repair and/or resection in a large cohort of patients with adhesive small bowel obstruction (SBO) managed operatively.Laparoscopic lysis of adhesions for adhesive SBO (aSBO) is becoming more common, yet might increase the risk of bowel injury given the distended and/or potentially compromised small bowel.We used administrative discharge data derived from a large geographic region, identifying patients who underwent surgery for their first episode of aSBO during 2005 to 2014. Procedure codes were used to determine the exposure: either an open approach or a laparoscopic approach (including procedures converted to open). The primary outcome was incidence of bowel intervention, defined as intraoperative enterotomy, suture repair of intestine, or bowel resection. We estimated the odds of bowel intervention after adjusting for patient and clinical factors.A total of 8584 patients underwent operation for aSBO. Patients undergoing laparoscopic procedures were younger with fewer comorbid conditions. The rate of laparoscopic approaches increased more than 3-fold during the study period (4.3%-14.3%, P0.0001). The incidence of bowel intervention was 53.5% versus 43.4% in laparoscopic versus open procedures (P0.0001). After adjustment for potential confounders, the odds of bowel intervention among patients treated laparoscopically versus open was 1.6 (95% confidence interval: 1.4-1.9).Laparoscopic procedures for aSBO are associated with a greater likelihood of intervention for bowel injury and/or repair. This increase might be due to challenges inherent with laparoscopic approaches in patients with distended small bowel. Surgeons should approach laparoscopic lysis of adhesions with a higher level of awareness and use strategies to mitigate this risk.

Background Improvements in survival after burns have resulted in more patients being discharged home after severe injury. However, the postdischarge health care needs of burn survivors are not well understood. We aimed to determine the rate and causes of unplanned presentation to acute care facilities in the 5 years after major burn injury. Methods Data derived from several population-based administrative databases were used to conduct a retrospective cohort study. All patients aged ≥16 years who survived to discharge after a major burn injury in 2003–2013 were followed for 1–5 years. All emergency department visits and unplanned readmissions were identified and classified by cause. Factors associated with emergency department visits were modeled using negative binomial generalized estimating equations. Factors associated with readmission were modeled using multivariable competing risk regression. Results We identified 1,895 patients who survived to discharge; 68% of patients had at least one emergency department visit and 30% had at least one readmission. Five-year mortality was 10%. The most common reason for both emergency department visits and readmissions was traumatic injury. After risk adjustment, patients who received their index care in a burn center experienced significantly less need for subsequent unplanned acute care, fewer emergency department visits (relative risk 0.61, 95% confidence interval, 0.52–0.72), and fewer hospital readmissions (hazard ratio 0.77, 95% confidence interval, 0.65–0.92). Conclusion Acute health care utilization is frequent after burn injury and is most commonly related to traumatic injuries. Burn-related events are uncommon beyond 30 days after discharge, suggesting low rates of burn recidivism. Patients treated at burn centers have significantly reduced unplanned health care utilization after their injury.

ObjectiveTo determine acute and long-term clinical, neuropsychological, and return-to-work (RTW) effects of electrical injuries (EIs). This study aims to further contrast sequelae between low-voltage and high-voltage injuries (LVIs and HVIs). We hypothesise that all EIs will result in substantial adverse effects during both phases of management, with HVIs contributing to greater rates of sequelae.DesignRetrospective cohort study evaluating EI admissions between 1998 and 2015.SettingProvincial burn centre and rehabilitation hospital specialising in EI management.ParticipantsAll EI admissions were reviewed for acute clinical outcomes (n=207). For long-term outcomes, rehabilitation patients, who were referred from the burn centre (n=63) or other burn units across the province (n=65), were screened for inclusion. Six patients were excluded due to pre-existing psychiatric conditions. This cohort (n=122) was assessed for long-term outcomes. Median time to first and last follow-up were 201 (68–766) and 980 (391–1409) days, respectively.Outcome measuresAcute and long-term clinical, neuropsychological and RTW sequelae.ResultsAcute clinical complications included infections (14%) and amputations (13%). HVIs resulted in greater rates of these complications, including compartment syndrome (16% vs 4%, p=0.007) and rhabdomyolysis (12% vs 0%, pConclusionsThis is the first investigation to determine acute and long-term patient outcomes post-EI as a continuum. Findings highlight substantial rates of neuropsychological and social sequelae, regardless of voltage. Specialised and individualised early interventions, including screening for mental health concerns, are imperative to improvingoutcomes of EI patients.

To determine whether restrictive fluid resuscitation results in increased rates of acute kidney injury (AKI) or infectious complications.Studies demonstrate that patients often receive volumes in excess of those predicted by the Parkland equation, with potentially detrimental sequelae. However, the consequences of under-resuscitation are not well-studied.Data were collected from a multicenter prospective cohort study. Adults with greater than 20% total burned surface area injury were divided into 3 groups on the basis of the pattern of resuscitation in the first 24 hours: volumes less than (restrictive), equal to, or greater than (excessive) standard resuscitation (4 to 6 cc/kg/% total burned surface area). Multivariable regression analysis was employed to determine the effect of fluid group on AKI, burn wound infections (BWIs), and pneumonia.Among 330 patients, 33% received restrictive volumes, 39% received standard resuscitation volumes, and 28% received excessive volumes. The standard and excessive groups had higher mean baseline APACHE scores (24.2 vs 16, P0.05 and 22.3 vs 16, P0.05) than the restrictive group, but were similar in other characteristics. After adjustment for confounders, restrictive resuscitation was associated with greater probability of AKI [odds ratio (OR) 3.25, 95% confidence interval (95% CI) 1.18-8.94]. No difference in the probability of BWI or pneumonia among groups was found (BWI: restrictive vs standard OR 0.74, 95% CI 0.39-1.40, excessive vs standard OR 1.40, 95% CI 0.75-2.60, pneumonia: restrictive vs standard, OR 0.52, 95% CI 0.26-1.05; excessive vs standard, OR 1.12, 95% CI 0.58-2.14).Restrictive resuscitation is associated with increased AKI, without changes in infectious complications.

Background Health administrative databases may provide rich sources of data for the study of outcomes following burn. We aimed to determine the accuracy of International Classification of Diseases diagnoses codes for burn in a population-based administrative database. Methods Data from a regional burn center’s clinical registry of patients admitted between 2006–2013 were linked to administrative databases. Burn total body surface area (TBSA), depth, mechanism, and inhalation injury were compared between the registry and administrative records. The sensitivity, specificity, and positive and negative predictive values were determined, and coding agreement was assessed with the kappa statistic. Results 1215 burn center patients were linked to administrative records. TBSA codes were highly sensitive and specific for ≥10 and ≥20% TBSA (89/93% sensitive and 95/97% specific), with excellent agreement ( κ , 0.85/ κ , 0.88). Codes were weakly sensitive (68%) in identifying ≥10% TBSA full-thickness burn, though highly specific (86%) with moderate agreement ( κ , 0.46). Codes for inhalation injury had limited sensitivity (43%) but high specificity (99%) with moderate agreement ( κ , 0.54). Burn mechanism had excellent coding agreement ( κ , 0.84). Conclusions Administrative data diagnosis codes accurately identify burn by burn size and mechanism, while identification of inhalation injury or full-thickness burns is less sensitive but highly specific.

We present newly acquired paleomagnetic data from Bandelier Tuff exposures in the Jemez Mountains (New Mexico) that show no statistically significant tectonic rotation over Quaternary time. Cooling units of the tuff were mapped in detail and correlated using new geochemical data, allowing us to confidently sample isochronous units for paleomagnetic remanence directions. In total, 410 specimens were subjected to step-wise thermal and alternating field demagnetization. Of the 40 accepted site means, 30 have α 95 values ≤5°. Analysis of the geographic distribution of the site-mean declinations of the data set reveals no statistically significant tectonic rotation either across (northwest/southeast) the northeast-striking Jemez fault or across (east/west) the north-striking Pajarito fault zone. Similarly, our data do not record any measurable relative change in declination difference (−1.1° ± 1.6°) that could be interpreted as a rotation over the ∼0.36 m.y. time duration between deposition of the two principal stratigraphic members of the Bandelier Tuff. The step-over discussed in this paper is an area of exceptional structural complexity and, as such, meets the definition of “accommodation zone.” We propose the name “Jemez-Embudo accommodation zone” for this composite of structural and volcanic features in recognition of its regional importance in the evolution of the Rio Grande rift. In this part of the rift, where Proterozoic- and Laramide-age faults have preconditioned the crust, idealized relay ramps, prevalent locally, do not occur at the regional scale. Instead, transfer fault zones have developed between half grabens dominated by preexisting faults. The pattern of faulting and accommodation of strain in the right-relayed step-over of the rift has been more or less invariant since the onset of rifting. From a global perspective, the difference between areas of modest crustal extension dominated by distributed deformation and those regions that develop transfer fault zones may ultimately be diagnostic of crustal conditioning and fault strength, such that weak fault systems focus strain within narrow zones.

Apolipoprotein E (APOE) is the strongest genetic risk factor for Alzheimer's disease (AD). Previous studies suggest that the effect of apoE on amyloid-beta (A beta) accumulation plays a major role in AD pathogenesis. Therefore, understanding proteins that control apoE metabolism may provide new targets for regulating A beta levels. LDLR, a member of the LDL receptor family, binds to apoE, yet its potential role in AD pathogenesis remains unclear. We hypothesized that LDLR overexpression in the brain would decrease apoE levels, enhance A beta clearance, and decrease A beta deposition. To test our hypothesis, we created several transgenic mice that overexpress LDLR in the brain and found that apoE levels in these mice decreased by 50%-90%. Furthermore, LDLR overexpression dramatically reduced A beta aggregation and enhanced A beta clearance from the brain extracellular space. Plaque-associated neuroinflammatory responses were attenuated in LDLR transgenic mice. These findings suggest that increasing LDLR levels may represent a novel AD treatment strategy.

BACKGROUND: Significant variation exists across registries in the criteria used to identify patients with no chance of survival, with potential for profound impact on trauma center mortality. The purpose of this study was to identify the optimal case definition for the unsalvageable patient, for the purpose of exclusion from performance improvement (PI) endeavors. METHODS: Data were derived from the American College of Surgeons' Trauma Quality Improvement Program for 2012 to 2013. We proposed three potential case definitions for the unsalvageable patient: (1) no signs of life as determined by local providers (NSOL), (2) prehospital cardiac arrest (PHCA), and (3) a proxy definition (PROXY) based on presenting vital signs, defined as emergency department (ED) heart rate = 0, ED systolic blood pressure = 0, and Glasgow Coma Scale score motor component = 1. Case definitions were compared using standard predictive tests to determine specificity and positive predictive value (PPV) for in-hospital mortality. After the optimal definition was identified, hierarchical logistic regression was used to assess the impact of including unsalvageable patients on trauma center risk-adjusted mortality. The impact on trauma center performance was determined as change in outlier status and performance decile after exclusion of patients who met the optimal case definition. RESULTS: During the study period, 223,643 patients met inclusion criteria across 192 trauma centers. Overall in-hospital mortality was 7.2%. The PROXY definition had excellent PPV for death, with less than 1% of patients meeting the PROXY criterion surviving. By contrast, NSOL and PHCA had PPVs low enough such that many of these patients went on to live (33% and 10%, respectively). After exclusion of patients who met the PROXY definition, 7% of trauma centers changed performance decile. This change was greatest for patients with penetrating injury and shock, with change in performance decile at 23% and 33% of centers, respectively. CONCLUSION: The PROXY case definition has excellent predictive utility to identify patients who, based on presenting vital signs, will go on to die. PROXY should be used to exclude unsalvageable patients from PI endeavors. Language: en

SUMMARY The role of MHC class II in the presentation of Heligmosomoides polygyrus antigens has been investigated, using a number of T cell hybridomas produced in A and E positive and negative mice. By using fixed and irradiated antigen presenting cells (APC), further evidence has emerged, to support earlier data, that there can be differential processing requirements during the presentation of H. polygyrus antigens by A and E molecules. In concordance with these earlier observations, this work provides further evidence that individual T cells can respond to antigen when presented by more than one MHC molecule. Previously, this evidence has been restricted to individual MHC molecules of the same haplotype, hut these data show that H. polygyrus produces antigens which can he presented by both syngeneic and allogeneic MHC molecules. These antigens do not appear to be synonymous with the previously described H. polygyrus superantigen, as presentation is restricted to specific MHC haplotypes. It is proposed that H. polygyrus may produce these antigenic molecules as part of its strategy to manipulate the host immune system.

Patients with severe traumatic brain injury (sTBI) are at high risk for developing venous thromboembolism (VTE). Nonetheless, pharmacologic VTE prophylaxis is often delayed out of concern for precipitating extension of intracranial hemorrhage (ICH). The purpose of this study was to compare the effectiveness of early vs late VTE prophylaxis in patients with sTBI, and to characterize the risk of subsequent ICH-related complication.Adults with isolated sTBI (head Abbreviated Injury Scale score ≥3 and total Glasgow Coma Scale score ≤8) who received VTE prophylaxis with low-molecular-weight or unfractionated heparin were derived from the American College of Surgeons Trauma Quality Improvement Program (2012 to 2014). Patients were divided into EP (72 hours) or LP (≥72 hours) groups. Propensity score matching was used to minimize selection bias. The primary end point was VTE (pulmonary embolism or deep vein thrombosis). Secondary outcomes were defined as late neurosurgical intervention (≥72 hours) or death.We identified 3,634 patients with sTBI. Early prophylaxis was given in 43% of patients. Higher head injury severity, presence of ICH, and early neurosurgery were associated with late prophylaxis. Propensity score matching yielded a well-balanced cohort of 2,468 patients. Early prophylaxis was associated with lower rates of both pulmonary embolism (odds ratio = 0.48; 95% CI, 0.25-0.91) and deep vein thrombosis (odds ratio = 0.51; 95% CI, 0.36-0.72), but no increase in risk of late neurosurgical intervention or death.In this observational study of patients with sTBI, early initiation of VTE prophylaxis was associated with decreased risk of pulmonary embolism and deep vein thrombosis, but no increase in risk of late neurosurgical intervention or death. Early prophylaxis may be safe and should be the goal for each patient in the context of appropriate risk stratification.

Few biomechanical studies exist on femoral cementless press-fit stems for revision total knee replacement (TKR) surgeries. The aim of this study was to compare the mechanical quality of the femur–stem interface for a series of commercially available press-fit stems, because this interface may be a ‘weak link’ which could fail earlier than the femur–TKR bond itself. Also, the femur–stem interface may become particularly critical if distal femur bone degeneration, which may necessitate or follow revision TKR, ever weakens the femur–TKR bond itself. The authors implanted five synthetic femurs each with a Sigma Short Stem (SSS), Sigma Long Stem (SLS), Genesis II Short Stem (GSS), or Genesis II Long Stem (GLS). Axial stiffness, lateral stiffness, ‘offset load’ torsional stiffness, and ‘offset load’ torsional strength were measured with a mechanical testing system using displacement control. Axial (range = 1047–1461 N/mm, p = 0.106), lateral (range = 415–462 N/mm, p = 0.297), and torsional (range = 115–139 N/mm, p > 0.055) stiffnesses were not different between groups. The SSS had higher torsional strength (863 N) than the other stems (range = 167–197 N, p