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  • Post-Acute Care Setting is Associated With Employment After Burn Injury. Archives of physical medicine and rehabilitation Espinoza, L. F., Simko, L. C., Goldstein, R., McMullen, K. A., Slocum, C., Silver, J. K., Herndon, D. N., Suman, O. E., Meyer, W. J., Gibran, N. S., Kowalske, K., Zafonte, R., Ryan, C. M., Schneider, J. C. 2019

    Abstract

    OBJECTIVE: To examine differences in long-term employment outcomes of adult burn survivors by post-acute care setting.DESIGN: Retrospective review of the prospectively collected Burn Model System National Database.SETTING: and Participants: A total of 695 adult burn survivors enrolled between May 1994 and June 2016 who required post-acute care at a Burn Model System center following acute care discharge were included. Participants were divided into two groups based on acute care discharge disposition. Those who received post-acute care at an inpatient rehabilitation facility (IRF) following acute care were included in the IRF group (N=447), and those who were treated at a skilled nursing facility, long-term care hospital, or other extended care facility following acute care were included in the Other Rehab Group (N=248).INTERVENTIONS: Not applicable.MAIN OUTCOME MEASURES: Employment status at 12 months post injury. Propensity score matching and logistic regression were utilized to determine the impact of post-acute care setting on employment status.RESULTS: Individuals in the IRF Group had larger burns and were more likely to have an inhalation injury and to undergo amputation. At 12 months post-injury, the IRF Group had over 9 times increased odds of being employed compared to the Other Rehab Group, using propensity score matching (p=0.046).CONCLUSIONS AND IMPLICATIONS: While admitting patients with more severe injuries, IRFs provided a long-term benefit for burn survivors in terms of regaining employment. Given the current lack of evidence-based guidelines on post-acute care decisions, the results of this study shed light on the potential benefits of the intensive services provided at IRFs in this population.

    View details for DOI 10.1016/j.apmr.2019.06.007

    View details for PubMedID 31278926

  • Investigation into Possible Association of Oxandrolone and Heterotopic Ossification Following Burn Injury JOURNAL OF BURN CARE & RESEARCH Thorpe, C. R., Ozgurel, S., Simko, L. C., Goldstein, R., Grant, G. G., Pagani, C., Hwang, C., Vasquez, K., Sorkin, M., Vaishampayan, A., Goverman, J., Sheridan, R. L., Friedstat, J., Schulz, J. T., Schneider, J. C., Levi, B., Ryan, C. M. 2019; 40 (4): 398–405
  • A Comparison of Contracture Severity at Acute Discharge in Patients With and Without Heterotopic Ossification: A Burn Model System National Database Study JOURNAL OF BURN CARE & RESEARCH Yelvington, M. L., Godleski, M., Lee, A. F., Goverman, J., Herndon, D. N., Suman, O. E., Kowalske, K. J., Holavanahalli, R. K., Gibran, N. S., Esselman, P. C., Simko, L. C., Ryan, C. M., Schneider, J. C. 2019; 40 (3): 349–54
  • Challenges to the Standardization of Trauma Data Collection in Burn, Traumatic Brain Injury, Spinal Cord Injury, and Other Trauma Populations: A Call for Common Data Elements for Acute and Longitudinal Trauma Databases ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Simko, L. C., Chen, L., Amtmann, D., Gibran, N., Herndon, D., Kowalske, K., Miller, A., Bulger, E., Friedman, R., Wolfe, A., Chung, K. K., Mosier, M., Jeng, J., Giacino, J., Zafonte, R., Kazis, L. E., Schneider, J. C., Ryan, C. M. 2019; 100 (5): 891–98
  • Investigation into Possible Association of Oxandrolone and Heterotopic Ossification Following Burn Injury. Journal of burn care & research : official publication of the American Burn Association Thorpe, C. R., Ucer Ozgurel, S., Simko, L. C., Goldstein, R., Grant, G. G., Pagani, C., Hwang, C., Vasquez, K., Sorkin, M., Vaishampayan, A., Goverman, J., Sheridan, R. L., Friedstat, J., Schulz, J. T., Schneider, J. C., Levi, B., Ryan, C. M. 2019

    Abstract

    Oxandrolone, a testosterone analog, is used to counteract the catabolic effects of burn injury. Recent animal studies suggest a possible hormonal association with heterotopic ossification (HO) development postburn. This work examines oxandrolone administration and HO development by exploring historical clinical data bridging the introduction of oxandrolone into clinical practice. Additionally, we examine associations between oxandrolone administration and HO in a standardized mouse model of burn/trauma-related HO. Acutely burned adults admitted between 2000 and 2014, survived through discharge, and had a HO risk factor of 7 or higher were selected for analysis from a single burn center. Oxandrolone administration, clinical and demographic data, and elbow HO were recorded and were analyzed with logistic regression. Associations of oxandrolone with HO were examined in a mouse model. Mice were administered oxandrolone or vehicle control following burn/tenotomy to examine any potential effect of oxandrolone on HO and were analyzed by Student's t test. Subjects who received oxandrolone had a higher incidence of elbow HO than those that did not receive oxandrolone. However, when controlling for oxandrolone administration, oxandrolone duration, postburn day oxandrolone initiation, HO risk score category, age, sex, race, burn size, and year of injury, there was no significant difference between rates of elbow HO between the two populations. In agreement with the review, in the mouse model, while there was a trend toward the oxandrolone group developing a greater volume of HO, this did not reach statistical significance.

    View details for PubMedID 31053861

  • A comparison of contracture severity at acute discharge in patients with and without heterotopic ossification: A Burn Model System National Database Study. Journal of burn care & research : official publication of the American Burn Association Yelvington, M., Godleski, M., Lee, A. F., Goverman, J., Herndon, D. N., Suman, O. E., Kowalske, K., Holavanahalli, R., Gibran, N. S., Esselman, P., Simko, L. C., Ryan, C. M., Schneider, J. C. 2019

    Abstract

    OBJECTIVE: This study assesses the association between heterotopic ossification and upper extremity contracture by comparing goniometric measured active range of motion outcomes of patients with and without heterotopic ossification.METHODS: Data was obtained from the Burn Model System National Database between 1994 and 2003 for patients over 18 years with elbow contracture at acute discharge. Absolute losses in elbow range of motion were compared for those with and without radiologic evidence of heterotopic ossification (location undefined) and were further examined by burn size subgroups using Wilcoxon rank-sum test. Differences in elbow range of motion were estimated using regression models, adjusted for demographic and clinical variables. Loss of range of motion of shoulder, wrist, forearm and hand were also compared.RESULTS: From 407 instances of elbow contracture, the subjects with heterotopic ossification were found to have greater median absolute loss of elbow flexion among all survivors (median 50° (IQR 45°) vs. 20° (30°), p<0.0001), for the 20-40% total body surface area burn subgroup (70° (20°) vs. 20° (30°), p=0.0008) and for the >40% subgroup (50° (45°) vs. 30° (32°), p=0.03). The adjusted estimate of the mean difference in the absolute loss of elbow flexion between groups was 23.5° (SE ±7.2°, p=0.0013).CONCLUSIONS: This study adds to our understanding of the potential effect of heterotopic ossification on upper extremity joint range of motion, demonstrating significant association between presence of heterotopic ossification and elbow flexion contracture severity. Further study is needed to determine the functional implications of heterotopic ossification and develop treatment protocols.

    View details for PubMedID 30838385

  • Head and neck burns are associated with long-term patient-reported dissatisfaction with appearance: A Burn Model System National Database study. Burns : journal of the International Society for Burn Injuries Sinha, I., Nabi, M., Simko, L. C., Wolfe, A. W., Wiechman, S., Giatsidis, G., Bharadia, D., McMullen, K., Gibran, N. S., Kowalske, K., Meyer, W. J., Kazis, L. E., Ryan, C. M., Schneider, J. C. 2019

    Abstract

    Burns affecting the head and neck (H&N) can lead to significant changes in appearance. It is postulated that such injuries have a negative impact on patients' social functioning, quality of life, physical health, and satisfaction with appearance, but there has been little investigation of these effects using patient reported outcome measures. This study evaluates the effect of H&N burns on long-term patient reported outcomes compared to patients who sustained burns to other areas.Data from the National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System National Database collected between 1996 and 2015 were used to investigate differences in outcomes between those with and without H&N burns. Demographic and clinical characteristics for adult burn survivors with and without H&N burns were compared. The following patient-reported outcome measures, collected at 6, 12, and 24 months after injury, were examined: satisfaction with life (SWL), community integration questionnaire (CIQ), satisfaction with appearance (SWAP), short form-12 physical component score (SF-12 PCS), and short form-12 mental component score (SF-12 MCS). Mixed regression model analyses were used to examine the associations between H&N burns and each outcome measure, controlling for medical and demographic characteristics.A total of 697 adults (373 with H&N burns; 324 without H&N burns) were included in the analyses. Over 75% of H&N injuries resulted from a fire/flame burn and those with H&N burns had significantly larger burn size (p<0.001). In the mixed model regression analyses, SWAP and SF-12 MCS were significantly worse for adults with H&N burns compared to those with non-H&N burns (p<0.01). There were no significant differences between SWL, CIQ, and SF-12 PCS.Survivors with H&N burns demonstrated community integration, physical health, and satisfaction with life outcomes similar to those of survivors with non-H&N burns. Scores in these domains improved over time. However, survivors with H&N burns demonstrated worse satisfaction with their appearance. These results suggest that strategies to address satisfaction with appearance, such as reconstructive surgery, cognitive behavior therapy, and social skills training, are an area of need for survivors with H&N burns.

    View details for PubMedID 30732865

  • Distinct behavioral response of primary motor cortex stimulation in itch and pain after burn injury. Neuroscience letters Thibaut, A., Ohrtman, E. A., Morales-Quezada, L., Simko, L. C., Ryan, C. M., Zafonte, R., Schneider, J. C., Fregni, F. 2018

    Abstract

    It is still unclear whether chronic neuropathic pain and itch share similar neural mechanisms. They are two of the most commonly reported challenges following a burn injury and can be some of the most difficult to treat. Transcranial direct current stimulation (tDCS) has previously been studied as a method to modulate pain related neural circuits. Therefore, we aimed to test the effects of tDCS on post-burn neuropathic pain and itch as to understand whether this would induce a simultaneous modulation of these two sensory manifestations. We conducted a pilot randomized controlled clinical trial comprised of two phases of active or sham M1 tDCS (Phase I: 10 sessions followed by a follow-up period of 8 weeks; Phase II: additional 5 sessions followed by a follow-up period of 8 weeks, and a final visit 12 months from baseline). Pain levels were assessed with the Brief Pain Inventory (BPI) and levels of itch severity were assessed with the Visual Analogue Scale (VAS). Measurements were collected at baseline, after the stimulation periods, at 2, 4 and 8-week follow up both for Phase I and II, and at the final visit. Sixteen patients were assigned to the active group and 15 to the sham group. Ten sessions of active tDCS did not reduce the level of pain or itch. We identified that itch levels were reduced at 2-week follow-up after the sham tDCS session, while no placebo effect was found for the active group. No difference between active and sham groups was observed for pain. We did not find any treatment effects during Phase II. It seems that an important placebo effect occurred during sham tDCS for itch, while active M1 tDCS seems to disrupt sensory compensatory mechanisms. Based on these results, we hypothesize that pain and itch are complementary but distinct mechanisms of adaptation after peripheral sensory injury following a burn injury and need to be treated differently.

    View details for PubMedID 30312754

  • Social Interactions and Social Activities after Burn Injury: A Life Impact Burn Recovery Evaluation (LIBRE) Study. Journal of burn care & research : official publication of the American Burn Association Ohrtman, E. A., Shapiro, G. D., Simko, L. C., Dore, E., Slavin, M. D., Saret, C., Amaya, F., Lomelin-Gascon, J., Pengsheng, N., Acton, A., Marino, M., Kazis, L. E., Ryan, C. M., Schneider, J. C. 2018

    Abstract

    Social interactions and activities are key components of social recovery following burn injuries. The objective of this study is to determine the predictors of these areas of social recovery.This study provides a secondary analysis of a cross-sectional survey of adult burn survivors. The Life Impact Burn Recovery Evaluation-192 was administered to 601 burn survivors for the field-testing of the Life Impact Burn Recovery Evaluation Profile. Survivors aged 18 years and older with injuries ≥5% total body surface area or burns to critical areas (hands, feet, face, or genitals) were eligible to participate. Multivariate linear regression analyses were used to determine predictors of the Social Activities and Social Interactions scale scores.A total of 599 people completed the Social Interactions and Social Activities scales. Of these, 77% identified as White Non-Hispanic, 55% were female, 55% were unmarried, and 80% had burns to critical areas. Participants had a mean age of 45 years, a mean time since burn injury of 15 years, and a mean burn size of 41% total body surface area. Younger age (p<0.01) and being married/living with a significant other (p≤0.01) were associated with higher Social Activities and Social Interactions scale scores. Individual item responses reveal that survivors had lower scores on items related to participating in outdoor activities (30.4%) or feeling uncomfortable with their appearance (32.4% report dressing to avoid stares).Social interactions and activities are long-term challenges for burn survivors. It is important for clinicians to identify patients who may struggle with social recovery in order to focus on future community based interventions.

    View details for PubMedID 30016442

  • Fatigue Following Burn Injury: A Burn Model System National Database Study JOURNAL OF BURN CARE & RESEARCH Simko, L. C., Espinoza, L. F., McMullen, K., Herndon, D. N., Suman, O., Fauerbach, J. A., Kowalske, K., Wiechman, S., Kazis, L. E., Ryan, C. M., Schneider, J. C. 2018; 39 (3): 450–56

    Abstract

    Fatigue is a commonly reported but not well-documented symptom following burn injury. This study's objective was to determine the frequency and severity of fatigue over time and to identify predictors of fatigue in the adult burn population. Data from the Burn Model System National Database (April 1997 to January 2006) were analyzed. Individuals over 18 years of age who were alive at discharge were included. The vitality subscale of the Short-Form 36 Item Health Survey was examined at preinjury and discharge and at 6, 12, and 24 months postinjury. Mean and number of low vitality scores were calculated at each time interval. Descriptive statistics were generated for demographic and medical data. Cross-sectional regression models analyzed predictors of vitality at 6, 12, and 24 months postinjury. The study included 945 subjects. The population was 72.5% male and had a mean age of 40.6 years and mean burn size of 17.4%. Fatigue symptoms were present in a majority of the population (74.6%) and were most commonly reported at discharge. Although fewer burn survivors reported fatigue symptoms at each subsequent follow-up (P < .001), approximately one-half (49%) of the population continued to report fatigue symptoms at 24 months postinjury. Larger burn size was the only variable that was significant or approaching significance at all follow-up time points (P < .0167). Fatigue symptoms are common after burns and many burn survivors continue to report symptoms at 2 years postinjury. Burn survivors did not return to preinjury fatigue levels, highlighting the importance of understanding and monitoring fatigue.

    View details for PubMedID 28877130

  • Challenges to the Standardization of Burn Data Collection: A Call for Common Data Elements for Burn Care JOURNAL OF BURN CARE & RESEARCH Schneider, J. C., Chen, L., Simko, L. C., Warren, K. N., Brian Phu Nguyen, Thorpe, C. R., Jeng, J. C., Hickerson, W. L., Kazis, L. E., Ryan, C. M. 2018; 39 (2): 201–8

    Abstract

    The use of common data elements (CDEs) is growing in medical research; CDEs have demonstrated benefit in maximizing the impact of existing research infrastructure and funding. However, the field of burn care does not have a standard set of CDEs. The objective of this study is to examine the extent of common data collected in current burn databases.This study examines the data dictionaries of six U.S. burn databases to ascertain the extent of common data. This was assessed from a quantitative and qualitative perspective. Thirty-two demographic and clinical data elements were examined. The number of databases that collect each data element was calculated. The data values for each data element were compared across the six databases for common terminology. Finally, the data prompts of the data elements were examined for common language and structure.Five (16%) of the 32 data elements are collected by all six burn databases; additionally, five data elements (16%) are present in only one database. Furthermore, there are considerable variations in data values and prompts used among the burn databases. Only one of the 32 data elements (age) contains the same data values across all databases.The burn databases examined show minimal evidence of common data. There is a need to develop CDEs and standardized coding to enhance interoperability of burn databases.

    View details for PubMedID 28481759

  • Quantifying Contracture Severity at Hospital Discharge in Adults: A Burn Model System National Database Study. Journal of burn care & research : official publication of the American Burn Association Godleski, M., Lee, A. F., Goverman, J., Herndon, D. N., Suman, O. E., Kowalske, K. J., Holavanahalli, R. K., Gibran, N. S., Esselman, P. C., Simko, L. C., Ryan, C. M., Schneider, J. C. 2018; 39 (4): 604–11

    Abstract

    Contracture is a common complication of burn injury and can cause significant barriers to functional recovery and rehabilitation. There are limited studies of quantitative range of motion after burn injury. The purpose of this study is to examine quantitative contracture outcomes by anatomical location, burn size, and length of stay in adults. Data were obtained from the Burn Model System National Database from 1994 to 2003. All adult patients with a joint contracture at acute discharge were included and 16 joint motions were examined. Contractures were reported as both mean absolute loss of normal range of motion in degrees and percent loss of normal range of motion. Analysis of variance was used to assess for a linear trend for contracture severity by burn size and length of stay. Data from 659 patients yielded 6,228 instances of contracture. Mean absolute loss of normal range of motion ranged from 20° to 65° representing an 18 to 45% loss of normal movement across the studied joint motions. In the majority of joint motions, contracture severity significantly increased with larger burn size and longer length of stay; however, wrist and many lower extremity joint movements did not demonstrate this trend. The data illustrate the quantitative assessment of range of motion deficits in adults with burn injury at discharge and the relation to burn size and length of stay.

    View details for PubMedID 29901805

  • Predicting Heterotopic Ossification Early After Burn Injuries A Risk Scoring System ANNALS OF SURGERY Schneider, J. C., Simko, L. C., Goldstein, R., Shie, V. L., Chernack, B., Levi, B., Jayakumar, P., Kowalske, K. J., Herndon, D. N., Gibran, N. S., Ryan, C. M. 2017; 266 (1): 179–84

    Abstract

    The purpose of this study is to develop a scoring system that stratifies burn patients at the time of hospital admission according to risk of developing heterotopic ossification (HO).HO in burns is an uncommon but severely debilitating problem with a poorly understood mechanism and no fully effective prophylactic measures.Data were obtained from the Burn Model System National Database from 1994 to 2010 (n = 3693). The primary outcome is diagnosis of HO at hospital discharge. Logistic regression analysis was used to determine significant demographic and medical predictors of HO. A risk scoring system was created in which point values were assigned to predictive factors and final risk score is correlated with the percent risk of developing HO. The model was internally and externally validated.The mean age of the subjects is 42.5 ± 16.0 years, the mean total body surface area (TBSA) burned is 18.5 ± 16.4%, and the population is 74.9% male. TBSA and the need for grafting of the arm, head/neck, and trunk were significant predictors of HO development (P < 0.01). A 13-point risk scoring system was developed using these significant predictors. The model c-statistic is 0.92. The risk scoring system demonstrated evidence of internal and external validity. An online calculator was developed to facilitate translation of knowledge to practice and research.This HO risk scoring system identifies high-risk burn patients suitable for diagnostic testing and interventional HO prophylaxis trials.

    View details for PubMedID 27348865