Dhaval Bhavsar

Pilot trial of telemedicine as a decision aid for patients with chronic wounds.

The study goal was to evaluate the impact of the telemedicine consult on patients with chronic wounds. Thirty patients from long-term care skilled nursing facilities, referred to the ambulatory wound care program for wound assessment and preparation of management plans, were the subject of this prospective, randomized trial. To facilitate communication with a surgical wound care specialist, telemedicine feedback was provided prior to face-to-face consultation to 15 patients. The telemedicine consult included (1) wound assessment, (2) rationale for the suggested wound management with emphasis on wound risk projections, and (3) prevention and benefits of surgical intervention. This was communicated to the patient by the field wound care nurse. The telemedicine impact was measured by assessing the duration of the subsequent face-to-face consultation and patient satisfaction with further care decisions as well as by validation of a decisional conflict scale. The average duration of the face-to-face consultation was 50 +/- 12 minutes versus 35 +/- 6 (p < 0.01) minutes for patients subjected to the telemedicine feedback preceding the direct contact with the specialist. The telemedicine consult was found to be a useful aid in increasing the satisfaction rate from care decisions ultimately made during the direct consult (acceptance rate 93% vs. 47% in those subjected to treatment without the intermediate telemedicine consult, p < 0.01). The decisional conflict as a state of uncertainty about the course of action to take was reduced in patients subjected to telemedicine decision aid. The average Decisional Conflict Scale score was 14 +/- 1.73 in patients subjected to telemedicine feedback as opposed to 35 +/- 4.26 (p < 0.001) in no-telemedicine contact. The telemedicine consult preceding face-to-face evaluation improved patient satisfaction and understanding of their care as well as increased the perception of shared decision making regarding the wound care.

Do telemedicine wound care specialist consults meet the needs of the referring physician? a survey of primary care providers

The purpose of our study was to determine the factors that influence the use of telemedicine consultation by primary care physicians (PCPs) in the management of patients with problem wounds. A short questionnaire was administered to thirty-six PCPs who referred to our Wound Care Program within one year. Participants were asked to rate the importance of specific concerns and benefits regarding the role of wound care surgical specialist (WCSS) and the use of telemedicine consults prior to possible face-to-face consultation. Sixty percent of respondents felt comfortable with telemedicine consultation based on recommendations alone. The total number of patients referred for telemedicine consult was 230, and face-to-face consultation with a WCSS was offered and arranged for 30% of patients. The perception of shared decision making, streamlining patient care, and an opportunity for followup were all highly ranked benefits. The majority of PCPs (93%) agreed that telemedicine wound care consult is a useful tool in their practice and would continue to use the telemedicine consult service.

Computerized insulin infusion programs are safe and effective in the burn intensive care unit.

Glucose control has repeatedly been shown to influence favorable outcomes in the surgical intensive care unit (ICU). Intensive insulin therapy has recently been associated with reduced infections complications in burn patients. However, traditional protocols are associated with rates of severe hypoglycemia as high as 19%. Two commercial computer glucose control programs have reported rates of severe hypoglycemia (glucose <50 mg/dl) of 0.6 and 0.4%. Recently, the authors’ burn ICU adopted an intensive insulin computer-based protocol created at their institution and already successfully in use in their surgical ICU. The authors hypothesized that their protocol can be used effectively in the burn patient population without an increase risk of severe hypoglycemia. All patients admitted to the burn ICU have blood glucose (BG) values checked routinely. With two consecutive hyperglycemic values >200 mg/dl, patients are placed on a computer-based protocol intravenous insulin drip. Once initiated, BGs are tested hourly with adjustments made according to the computer protocol. Values recorded from January to December 2008 were abstracted from the database and analyzed. Thirty-one patients were treated using the computer glucose control protocol and 12,699 measurements were performed. There were eight measurements <50 mg/dl (0.07%). Seventy-six percent of values were within the target range of 90 to 150 mg/dl. Few patients had severe hyperglycemia with BG >300 mg/dl (0.2%). There were no adverse events associated with the hypoglycemic episode. The computer-based protocol is more effective than those previously used at the institution and provides safe, reliable results in the burn patients.

Necrotizing metachronous facial ulcerations after "stem cell face lift".

IntroductionA 63-year-old woman underwent face and neck lift with autologous fat transfer—called by her physician a “stem cell face lift.” MethodsFatty aspirate from her abdominal wall was enriched by hyaluronic acid, triiodothyronine, thyroxine, insulin, dimethylaminoethanol, estriol, dexamethasone, indomethacin, and fibroblast growth factor before injection into the face. ResultsAt approximately 4-weeks postoperative, the patient developed facial swellings, erythema, necrotizing ulcers, and an orocutaneous fistula. New lesions continued occurring up to 16 weeks after surgery. After multiple surgical debridements and an oral course of rifampin, a decisive reduction in inflammation and healing was observed. Differential diagnosis included (1) mistaken transfer of allogeneic fat (ruled out), (2) toxic impurities in transferred material, (3) microbial contaminant(s) from multiple use liposuction cannula or tissue markers, and (4) endogenous anaerobic orofacial infection (history of previous radiation for tonsillar cancer and dental implants). ConclusionsThe most probable etiology was mycobacterial infection. This is based on a single colony of mycobacterium isolated, histologic finding revealing granulomatous inflammation, and the favorable response to rifampin. The patient underwent subsequent autologous fat transfers, which successfully reduced some disfigurement and scarring.

Sedation and Analgesia for Dressing Change: A Survey of American Burn Association Burn Centers.

Pain and sedation management for patients undergoing burn dressing change can be challenging. Variations appear to exist in the selection of medications before and during burn dressing change. To determine if institutional variations exist in pain and sedation management for burn dressing change, an online survey was sent to ABA Burn Center nurses and physicians. Three hundred seventy-eight anonymous responses were received from nurses (72%), nurse practitioners (10%), and physicians (18%). Burn centers had adult (22%), pediatric (12%), or pediatric and adult (66%) patients. Eighty percentage of centers had >200 patients/year. Sixty-eight percentage always used a premedication. Oxycodone and morphine or fentanyl was the most frequently used per oral (PO) and intravenous (IV) opioid premedication, respectively. The most common IV premedication anxiolytic were benzodiazepines. Sixty-eight percentage always used a long-acting opioid. Anesthetic regimen was decided case-by-case (47%) or specific protocol (24%). Protocol was followed always (18%) or mostly (55%). Patients’ procedural pain could be better controlled 20% of the time. Pain regimen was altered most of the time (25%). Providers differed rarely (39%) and sometimes (44%) regarding preferred regimen. Ketamine was the most common deep sedative. A dedicated anesthesiologist was rarely (33%) consulted, determined case-by-case (33%) or prior failure/excess pain (19%). Acute pain service was never (51%) or rarely (35%) consulted. Pain and sedation management for burn dressing change is difficult and variations in approach exist among burn centers. Such management needs individualized care. Providers must be responsive to pain alterations. Consultation with anesthesia providers may be needed in specific cases. Further studies need to be completed to demonstrate the most effective means of controlling burn pain and evaluating patient outcomes.

Transfusion Requirement in Burn Care Evaluation (TRIBE): A Multicenter Randomized Prospective Trial of Blood Transfusion in Major Burn Injury

Objective: Our objective was to compare outcomes of a restrictive to a liberal red cell transfusion strategy in 20% or more total body surface area (TBSA) burn patients. We hypothesized that the restrictive group would have less blood stream infection (BSI), organ dysfunction, and mortality. Background: Patients with major burns have major (>1 blood volume) transfusion requirements. Studies suggest that a restrictive blood transfusion strategy is equivalent to a liberal strategy. However, major burn injury is precluded from these studies. The optimal transfusion strategy in major burn injury is thus needed but remains unknown. Methods: This prospective randomized multicenter trial block randomized patients to a restrictive (hemoglobin 7–8u200ag/dL) or liberal (hemoglobin 10–11u200ag/dL) transfusion strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes. Results: Eighteen burn centers enrolled 345 patients with 20% or more TBSA burn similar in age, TBSA burn, and inhalation injury. A total of 7054 units blood were transfused. The restrictive group received fewer blood transfusions: mean 20.3u200a±u200a32.7 units, median = 8 (interquartile range: 3, 24) versus mean 31.8u200a±u200a44.3 units, median = 16 (interquartile range: 7, 40) in the liberal group (P < 0.0001, Wilcoxon rank sum). BSI incidence, organ dysfunction, ventilator days, and time to wound healing (P > 0.05) were similar. In addition, there was no 30-day mortality difference: 9.5% restrictive versus 8.5% liberal (P = 0.892, &khgr;2 test). Conclusions: A restrictive transfusion strategy halved blood product utilization. Although the restrictive strategy did not decrease BSI, mortality, or organ dysfunction in major burn injury, these outcomes were no worse than the liberal strategy (Clinicaltrials.gov identifier NCT01079247).

Restrictive Transfusion Strategy Is More Effective in Massive Burns: Results of the TRIBE Multicenter Prospective Randomized Trial

OBJECTIVESnStudies suggest that a restrictive transfusion strategy is safe in burns, yet the efficacy of a restrictive transfusion policy in massive burn injury is uncertain. Our objective: compare outcomes between massive burn (≥60% total body surface area (TBSA) burn) and major (20-59% TBSA) burn using a restrictive or a liberal blood transfusion strategy.nnnMETHODSnPatients with burns ≥20% were block randomized by age and TBSA to a restrictive (transfuse hemoglobin <7 g/dL) or liberal (transfuse hemoglobin <10 g/dL) strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes.nnnRESULTSnThree hundred and forty-five patients received 7,054 units blood, 2,886 in massive and 4,168 in restrictive. Patients were similar in age, TBSA, and inhalation injury. The restrictive group received less blood (45.57 ± 47.63 vs. 77.16 ± 55.0, p < 0.03 massive; 11.0 ± 16.70 vs. 16.78 ± 17.39, p < 0.001) major). In massive burn, the restrictive group had fewer ventilator days (p < 0.05). Median ICU days and LOS were lower in the restrictive group; wound healing, mortality, and infection did not differ. No significant outcome differences occurred in the major (20-59%) group (p > 0.05).nnnCONCLUSIONSnA restrictive transfusion strategy may be beneficial in massive burns in reducing ventilator days, ICU days and blood utilization, but does not decrease infection, mortality, hospital LOS or wound healing.

Parameters for Ordering Blood Cultures in Major Burn Injury Patients: Improving Clinical Assessment

Hypermetabolic and catabolic states in large TBSA burns lead to higher basal body temperature and tachycardia. These metabolic changes complicate the diagnosis of bacteremia and sepsis. Current indications for obtaining blood cultures (BCs) in this population are poorly described and nonstandardized. Fever, leukocytosis, and lactic acidosis are common during sepsis. This study aims to identify limits of these parameters with the highest rates of bacteremia. A retrospective review was performed for burn patients with > 20% TBSA between January 2009 and June 2011. BCs were collected with corresponding body temperature, white blood cell (WBC) count, and serum lactate levels. Positive culture rates were analyzed with univariate and multivariate analysis. Seventy-one patients met inclusion criteria and 360 BCs were included in data analysis. Cultures taken with temperature > 38.9°C were significantly more positive (P = .01) than temperatures between 38 and 38.9°C. There were significantly more positive cultures when the WBC count was < 4.5 compared with those ≥ 4.5u2009×u2009103/µl (P = .04). Lactate was an independent predictor of bacteremia (OR, 1.81; 95% CI, 1.21-12.71). Cultures were significantly more positive when the lactate level was ≥ 2.5 compared with < 2.5u2009mg/dL (P = .02). A temperature ≥ 38.5°C and a lactate ≥ 2.5u2009mg/dL corresponded to a 28.6% positive culture rate compared with 4.8% for all other scenarios (P = .001). This study demonstrates that body temperature > 38.9°C, WBC < 4.5u2009×u2009103/µl, and serum lactate ≥ 2.5u2009mg/dL have the highest rate for positive BCs in severe burn patients. A combination of leukopenia and pyrexia as well as lactic acidosis and pyrexia represent even higher specificity for positive BC in these patients.

Potential mechanisms underlying ectodermal differentiation of Wharton's jelly mesenchymal stem cells

Whartons jelly mesenchymal stem cells (WJMSCs) are being increasingly recognized for their ectodermal differentiation potential. Previously, we demonstrated that when WJMSC were seeded onto an acellular matrix material derived from Whartons jelly and cultured in osteogenic induction media, generated CK19 positive cells and hair-like structures indicative of ectodermal differentiation of WJMSCs. In this manuscript, we examine the underlying mechanism behind this observation using a variety of microscopy and molecular biology techniques such as western blotting and qPCR. We demonstrate that these hair-like structures are associated with live cells that are positive for epithelial and mesenchymal markers such as cytokeratin-19 and α-smooth muscle actin, respectively. We also show that up-regulation of β-catenin and noggin, along with the expression of TGF-β and SMAD and inhibition of BMP4 could be the mechanism behind this ectodermal differentiation and hair-like structure formation.