Patterns of deliberate self-burning in various parts of the world. A review

Suicide and self-harm by burns in Pakistan: a scoping review protocol

INTRODUCTION

Suicide is a global public health problem. Self-inflicted burns are one of the most severe methods of suicide, with high morbidity and mortality. Low-income and middle-income countries contribute 40% of all suicidal burns. Pakistan lacks comprehensive burns surveillance data, which prevents an understanding of the magnitude of the problem. This scoping review aims to understand the scope of the problem of suicide and self-harm burns in Pakistan and to identify knowledge gaps within the existing literature related to this specific phenomenon.

METHODS AND ANALYSIS

This scoping review will follow the methodological framework proposed by Arksey and O'Malley. We will search electronic databases (PubMed, Cochrane, Google Scholar and Pakmedinet), grey literature and a reference list of relevant articles to identify studies for inclusion. We will look for studies on self-inflicted burns as a method of suicide and self-harm in Pakistan, published from the beginning until December 2023, in the English language. Two independent reviewers will screen all abstracts and full-text studies for inclusion. The data will be collected on a data extraction form developed through an iterative process by the research team and it will be analysed using descriptive statistics.

ETHICS AND DISSEMINATION

Ethical exemption for this study has been obtained from the Institutional Review Board Committee of Aga Khan University Karachi, Pakistan. The findings of the study will be disseminated by conducting workshops for stakeholders, including psychiatrists, psychologists, counsellors, general and public health physicians and policymakers. The findings will be published in national and international peer-reviewed journals.

The Global Macroeconomic Burden of Burn Injuries

BACKGROUND

Standardized estimates of global economic losses from burn injuries are lacking. The primary objective of this study was to determine the global macroeconomic consequences of burn injuries and their geographic distribution.

METHODS

Using the Institute of Health Metrics and Evaluation database (2009 and 2019), mean and 95% uncertainty interval (UI) data on incidence, mortality, and disability-adjusted life-years (DALYs) from injuries caused by fire, heat, and hot substances were collected. Gross domestic product (GDP) data were analyzed together with DALYs to estimate macroeconomic losses globally using a value of lost welfare approach.

RESULTS

There were 9 million global burn cases (95% UI, 6.8 to 11.2 million) and 111,000 deaths from burns (95% UI, 88,000 to 132,000 deaths) in 2019, representing a total of 7.5 million DALYs (95% UI, 5.8 to 9.5 million DALYs). This represented welfare losses of $112 billion (95% UI, $78 to $161 billion), or 0.09% of GDP (95% UI, 0.06% to 0.13%). Welfare losses as a share of GDP were highest in low- and middle-income countries (LMICs) of Oceania (0.24%; 95% UI, 0.09% to 0.42%) and Eastern Europe (0.24%; 95% UI, 0.19% to 0.30%) compared with high-income country regions such as Western Europe (0.06%; 95% UI, 0.04% to 0.09%). Mortality-incidence ratios were highest in LMIC regions, highlighting a lack of treatment access, with southern sub-Saharan Africa reporting a mortality-incidence ratio of 40.1 per 1000 people compared with 1.9 for Australasia.

CONCLUSIONS

Burden of disease and resulting economic losses because of burn injuries are substantial worldwide and are disproportionately higher in LMICs. Possible effective solutions include targeted education, advocacy, and legislation to decrease incidence and investing in existing burn centers to improve treatment access.

Long-term mortality after self-inflicted burns

BACKGROUND

Those with self-inflicted burns are a small but consistent group among burn patients, with large injuries and conflicting findings regarding their in-hospital mortality. Overall, burn survivors have a shorter life expectancy, as compared with national controls, but long-term mortality after self-inflicted burns is understudied. The aim of this retrospective study was to investigate possible differences in long-term mortality among survivors after self-inflicted and accidental burns.

METHODS

All adult patients with burns admitted at the Linköping Burn Centre and discharged alive between 2000 and 2017 were included, and end of follow up was April 26, 2021. Those with unknown survival status at that time were excluded. A Cox proportional hazards regression model, adjusted for age and sex, was used to analyse long term mortality.

RESULTS

Among the 930 patients included in this study, 37 had self-inflicted burns. Overall, median follow up period was 8.8 years and crude mortality was 24.7%. After adjustment for age and sex, self-inflicted burns were independently associated with long-term mortality, Hazard Ratio= 2.08 (95% CI 1.13-3.83). Post hoc analysis showed that the effect was most pronounced during the first years after discharge although it was noticeable over the whole study period.

CONCLUSION

Long-term risk of mortality after discharge from a burn centre was higher in patients with self-inflicted burns than in patients with accidental burns. The effect was noticeable over the whole study period although it was most pronounced during the first years after discharge.

Examination of misconceptions surrounding fatal fire victims

Fire deaths are not unusual in forensic investigative practice but due to the destructive nature of fire they are often very difficult to investigate. With the need to identify the deceased and the events surrounding the manner and cause of death, knowledge of thermally induced alteration to the human body is important. Within the fire investigation community, a number of misconceptions have been present for years regarding the protrusion of the tongue as an indicator of life during the fire, and fractured skulls as the result of brains boiling and skulls exploding. This work presents qualitative analysis on the experimental burning of 42 unembalmed human donated cadavers by the San Luis Obispo Strike Team (SLOFIST) on their annual Forensic Fire Death Investigation Course (FFDIC) between 2017 and 2019. Prior to burning, the position of the tongue within the dental arch was confirmed and sharp, blunt, surgical and gunshot trauma to the cranium documented. Temperature was recorded from ignition through to suppression with thermocouples present both within the scene and the body. Post burn analysis on the position of the tongue, observation of cranial fractures and presence of brain tissue were recorded and analysed in conjunction with thermocouple data, fire scene dynamics and body demographics. The results provide a more comprehensive understanding of the thermal environmental factors involved in producing the phenomena that facilitate these misconceptions, identifying that a more thorough understanding of individual fire scenes and their development is essential when interpreting alteration and injury to the body of the fatal fire victim.

Terminology and methods used to differentiate injury intent of hospital burn patients in South Asia: a systematic scoping review protocol

BACKGROUND

The greatest proportion of burn injuries globally occur in South Asia, where there are also high numbers of intentional burns. Burn injury prevention efforts are hampered by poor surveillance data on injury intent. There is a plethora of local routinely collected data in the research literature from South Asia that could be used for epidemiological purposes, but it is not known whether the definitions and methods of differentiation of injury intent are sufficiently homogenous to allow valid study comparisons.

METHODS

We will conduct a systematic scoping review to understand terminology and methods used to differentiate injury intent of hospital burn patients in South Asia. The objectives of the study are to: determine the breadth of terminology and common terms used for burn injury intent; to determine if definitions are comparable across studies where the same term is used; and to appraise the rigour of methods used to differentiate burn injury intent and suitability for comparison across studies. The databases Embase, MEDLINE, CINAHL, PsycINFO, and PakMediNet will be searched. Screening and data extraction will be completed independently by two reviewers. To be included, the article must be as follows: peer reviewed, primary research, study cutaneous burns, based on hospital patients from a country in South Asia, and use intent terminology or discuss a method of differentiation of injury intent. Results will be restricted to English language studies. No date restrictions will be applied. A plain language summary and terminology section are included for non-specialist readers.

DISCUSSION

Results will be used to inform stakeholder work to develop standardised terminology and methods for burn injury intent in South Asia. They will be published open access in peer-reviewed journals wherever possible.

SYSTEMATIC REVIEW REGISTRATION

This review has been registered with the Open Science Framework ( https://doi.org/10.17605/OSF.IO/DCYNQ ).

Attempted Suicide by Burning: A Cross-sectional Analysis at a Regional Burn Center in Germany

Attempted suicide by self-immolation or burning constitutes an uncommon form of attempted suicide in high income countries, presenting substantial challenges to burn units. The aim of this study was to analyze the epidemiologic characteristics and outcomes in intensive care burn patients treated for attempted suicide by burning. For this purpose, we examined intensive care burn patients admitted to a single major burn unit between March 2007 and December 2020. Demographic, clinical, epidemiological, and mortality data were collected and analyzed. Major psychiatric comorbidities were evaluated according to ICD-9 and ICD-10 classifications. A total of 1325 intensive care unit burn patients were included. Suicide by burning was attempted in 45 cases (3.4%). Attempted suicide victims presented with significantly higher burn severity, reflected by higher abbreviated burn severity index scores, and larger TBSA affected. Burned TBSA ≥30% and inhalation injuries were observed more frequently in suicidal patients. These patients also experienced prolonged hospital and intensive care unit length of stay, required surgical interventions and mechanical ventilation more frequently, and had significantly longer periods on ventilation, causing an overall higher mortality rate (24.4%). Psychiatric comorbidities were present in 75.6% of patients who attempted suicide. Despite the low prevalence, burn severity and mortality are considerably high in patients who attempted suicide by burning, presenting a significant challenge for healthcare providers. The majority of patients had a history of psychiatric disorder, highlighting the importance of identifying patients at high-risk who may profit from increased psychiatric intervention.

Exploring the similarities and differences of variables collected by burn registers globally: protocol for a data dictionary review study

INTRODUCTION

Burn registers can provide high-quality clinical data that can be used for surveillance, research, planning service provision and clinical quality assessment. Many countrywide and intercountry burn registers now exist. The variables collected by burn registers are not standardised internationally. Few international burn register data comparisons are completed beyond basic morbidity and mortality statistics. Data comparisons across registers require analysis of homogenous variables. Little work has been done to understand whether burn registers have sufficiently similar variables to enable useful comparisons. The aim of this project is to compare the variables collected in countrywide and intercountry burn registers internationally to understand their similarities and differences.

METHODS AND ANALYSIS

Burn register custodians will be invited to participate in the study and to share their register data dictionaries. Study objectives are to compare patient inclusion and exclusion criteria of each participating burn register; determine which variables are collected by each register, and if variables are required or optional, identify common variable themes; and compare a sample of variables to understand how they are defined and measured. All variable names will be extracted from each register and common themes will be identified. Detailed information will be extracted for a sample of variables to give a deeper insight into similarities and differences between registers.

ETHICS AND DISSEMINATION

No patient data will be used in this project. Permission to use each register's data dictionary will be sought from respective register custodians. Results will be presented at international meetings and published in open access journals. These results will be of interest to register custodians and researchers wishing to explore international data comparisons, and countries wishing to establish their own burn register.

Retrospective Evaluation of Characteristics of Patients with Burn Injuries Treated at the Largest Reference Hospital in Brazil

Burn injuries are a significant cause of morbidity and mortality in the Brazilian population. We conducted this study in a tertiary hospital in Brazil to discover the epidemiological characteristics of patients with burn injuries. We conducted a cohort review of patients admitted to the burn unit of our institute during a 5-year period. For each patient, we collected data that included age, gender, total percentage of burned body surface area, burn location, burn mode, and burn cause. We analyzed the data using the R programming language. We included a total of 496 patients in our study. The mean age of the patients was 28 ± 14.7 years. The median length of hospital stay was 2 weeks. We found a significant correlation between the total percentage of burned body surface area and the length of hospitalization (p < .001) and the length of hospitalization in the intensive care unit (p < .001). A total of 427 patients (86%) were discharged from the hospital after successful treatment. In contrast, 43 patients (8.67%) died. The mortality rate was highest in patients who had more than 70% of their total body surface area burned. The average length of hospitalization aligned with global and national statistics presented in the literature. The main causes of the burn injuries were thermal (e.g., fire, hot liquids). We found inhalation injuries present in more than one third of the patients who were hospitalized in the intensive care unit with thermal burns.

Self-immolation in the Arab world: A systematic review

Self-immolation is the act of setting fire to oneself. Recent spikes in self-immolation events have been noticed in the Arab world, specifically in the aftermath of the Arab Spring in 2011. We aimed to examine the literature assessing the characteristics and patterns of suicide by self-immolation in the Arab world. We registered our systematic review in Prospero. We searched PubMed, Medline, PsycInfo, Embase, and Scopus databases from inception until 9 July 2022, along with other sources, following the PRISMA 2020 guidelines. We collected relevant articles tackling suicide by self-immolation in the Arab world via title and abstract screening followed by full-text screening. We then conducted a narrative synthesis of the results. Out of 326 records from databases and 17 additional records identified through other sources, 31 articles (27 quantitative and 4 qualitative) were included. The studies came from Iraq (n = 16), Tunisia (n = 6), Kingdom of Saudi Arabia (n = 3), Jordan (n = 2), Libya (n = 2), Bahrain (n = 1), and Egypt (n = 1). The quantitative studies had a sample size ranging from 22 to 600 self-inflicted burn victims. Studies showed that self-immolators were mostly married women with low educational level and low socioeconomic status. Self-immolation was more likely to happen at home, usually following marital conflicts. Kerosene was the accelerant used the most. Depression was the most comorbid mental health diagnosis. Studies highlighted that self-immolation was being increasignly used as a form of protest. Self-immolation is not uncommon in the Arab world. Specific interventions directed at the population at risk are warranted.

Knowledge, attitudes and experiences of self-harm and suicide in low-income and middle-income countries: protocol for a systematic review

INTRODUCTION

Over 800 000 people die due to suicide each year and suicide presents a huge psychological, economic and social burden for individuals, communities and countries as a whole. Low-income and middle-income countries (LMICs) are disproportionately affected by suicide. The strongest risk factor for suicide is a previous suicide attempt, and other types of self-harm have been found to be robust predictors of suicidal behaviour. An approach that brings together multiple sectors, including education, labour, business, law, politics and the media is crucial to tackling suicide and self-harm. The WHO highlights that evaluations of the knowledge and attitudes that priority groups, not only healthcare staff, have of mental health and suicidal behaviour are key to suicide prevention strategies. The aim of this systematic review is to examine the knowledge, attitudes and experiences different stakeholders in LMICs have of self-harm and suicide.

METHODS AND ANALYSIS

MEDLINE, Embase, PsycINFO, CINAHL, BNI, Social Sciences and Cochrane Library will be searched. Reviewers working independently of each other will screen search results, select studies for inclusion, extract and check extracted data, and rate the quality of the studies using the Strengthening the Reporting of Observational studies in Epidemiology and Critical Appraisals Skills Programme checklists. In anticipation of heterogeneity, a narrative synthesis of quantitative studies will be provided and metaethnography will be used to synthesise qualitative studies.

ETHICS AND DISSEMINATION

Ethical approval is not required. A report will be provided for the funding body, and the systematic review will be submitted for publication in a high-impact, peer-reviewed, open access journal. Results will also be disseminated at conferences, seminars, congresses and symposia, and to relevant stakeholders.

PROSPERO REGISTRATION NUMBER

CRD42019135323.

A burned body with a shotgun head injury found on an "altar" made of banknotes: A case report from Greece and brief review of the literature

We describe an unusual case of a burnt body with a shotgun head injury found on a "bed" made of wooden boards on a pile of banknotes, resembling an altar. The body belonged to a 64-year-old man, of Greek nationality, with cancer who set his house (including the room in which he was found) and vehicle on fire before shooting himself, planning this way his postmortem burning. The combination of fire with the use of an "altar" and the destruction of body and possessions creates a unique death scene that implies a suicide with a ritual character.

Psychosocial Determinants of Burn-Related Suicide: Evidence From the National Violent Death Reporting System

Suicide is a unique phenomenon in humans. In 2017, over 47,000 Americans died by suicide, prompting a public health crisis. Suicide by burning, while one of the rarest forms of suicide, could be mitigated in part by early recognition and treatment of the underlying psychosocial factors. To date, investigators have attempted to tease out the risk factors associated with this phenomenon through the examination of burn center chart reviews and repository data, but these studies were limited by small sample sizes. In order to fill this gap in the literature, the authors analyzed 14 years of data (2003-2016) from the National Violent Death Reporting System. Suicides by burning (n = 722) were compared with a reference group containing all other suicide types (n = 166,949). Socio-demographic variables and psychosocial factors (eg, mental health, substance use, and alcohol use) were included in the model. Due to the imbalance between the target and reference groups, rare event data analysis was used to reduce potential small sample estimation bias. Results indicated that females (OR = 1.6, 95% CI: .50-2.83, P < .001), Caucasians (OR = 1.7, 95% CI: 1.1-2.7, P < .001), victims with schizophrenia (OR = 5.4, 95% CI: 3.7-7.8, P < .001), and victims with eating disorders (OR = 5.6, 95% CI: 1.9-8.6, P < .001) are significantly more likely to commit suicide by burning. These results contribute new knowledge to what is currently known about suicidal burn-related behaviors and supports interventions that focus on mitigating this insidious public health problem.

Suicide by self-immolation in southern Iran: an epidemiological study

Background

Self-immolation, as a method of suicide, is one of the most violent and extreme ways which is usually attempted by the ignition of inflammable materials, with more than 70% fatality rate. In the literature, Iran has been reported to have a high rate of self-immolation; therefore, this study aimed to evaluate the prevalence and epidemiological features of self-immolated patients.

Methods

In this retrospective cross-sectional multicenter study, data from burn patients from 2007 till 2017 due to self-immolation and suicide were enrolled in our study.

Results

Based on our data, 657 out of 3530 burn patients (18.6%) with a mean age of 31.15 (SD = 0.452) were documented as suicidal attempts; the majority were female (63.2%) and married (66.3%). Most of the patients were from rural areas (58.3%) with an education level of under diploma (63.2%). Of the patients in our study, 22 (8.7%) had comorbid systemic diseases and 115 (50.5%) had psychiatric disorders.

Conclusion

Due to the high prevalence of suicide by self-immolation among the Iranian population, further studies to evaluate the risk factors and clarify the high-risk group for more targeted approaches are recommended.

Epidemiology of injuries from fire, heat and hot substances: global, regional and national morbidity and mortality estimates from the Global Burden of Disease 2017 study

BACKGROUND

Past research has shown how fires, heat and hot substances are important causes of health loss globally. Detailed estimates of the morbidity and mortality from these injuries could help drive preventative measures and improved access to care.

METHODS

We used the Global Burden of Disease 2017 framework to produce three main results. First, we produced results on incidence, prevalence, years lived with disability, deaths, years of life lost and disability-adjusted life years from 1990 to 2017 for 195 countries and territories. Second, we analysed these results to measure mortality-to-incidence ratios by location. Third, we reported the measures above in terms of the cause of fire, heat and hot substances and the types of bodily injuries that result.

RESULTS

Globally, there were 8 991 468 (7 481 218 to 10 740 897) new fire, heat and hot substance injuries in 2017 with 120 632 (101 630 to 129 383) deaths. At the global level, the age-standardised mortality caused by fire, heat and hot substances significantly declined from 1990 to 2017, but regionally there was variability in age-standardised incidence with some regions experiencing an increase (eg, Southern Latin America) and others experiencing a significant decrease (eg, High-income North America).

CONCLUSIONS

The incidence and mortality of injuries that result from fire, heat and hot substances affect every region of the world but are most concentrated in middle and lower income areas. More resources should be invested in measuring these injuries as well as in improving infrastructure, advancing safety measures and ensuring access to care.

Self-immolation Suicide in Greece: A Forensic Psychiatric Autopsy Study between 2011 and 2019

Self-immolation is a rare suicide method in the developed countries of the western world (0.06-1%); however, it has relatively higher prevalence rates in the developing countries of Asia and Africa (6-57%). The present study aims to examine self-immolation suicides within the Greek mainland (Attiki, Thrace, and Peloponnese) over a period of 9 years (2011-2019) in order to investigate the phenomenon in the Greek population forensically, identify the characteristics and motivations of suicide victims, explore its associations to socio-cultural or psychiatric factors, and describe a fatal case of suicide by self-immolation that was partially recorded on camera. The medical files (autopsy reports) of cases performed at the Departments of Forensic Medicine of the National and Kapodistrian University of Athens, Democritus University of Thrace, and the Forensic Service of Messinia-Peloponnese were retrospectively examined yielding 19 cases of suicides by self-immolation. A 3.7% prevalence of suicide by self-immolation among suicide fatalities within the Greek population was estimated. A distinctive feature of the Greek population regarding self-immolation was disclosed that it is being practiced predominantly by the elderly (mean age 2-3.5 decades higher than other countries). The phenomenon correlated strongly with poorly controlled mental disorders (mostly affective and adjustment disorders). Unlike other countries, there was no significant association with domestic or sexual violence, social or political protest, or religious issues. Therefore, the suicide victims preferred secluded or private outdoor locations (not public). Findings deriving from the examined variables localize Greek population culturally between the Western European and Asian African countries, but with its own idiosyncrasies.

Self-inflicted Burn Injury Is Independently Associated With Increased Mortality in a More Economically Developed Country: A Propensity Score Matching Analysis

Self-inflicted burn accounts for considerable morbidity and mortality in more economically developed countries, and there is a substantial debate regarding the pathophysiological relevance between self-inflicted burns and unfavorable outcomes. To validate whether self-inflicted injury is an independent predictor of high mortality regardless of the severity of burn, they conducted a retrospective observational study using the Japan Trauma Data Bank, a nationwide database including over 200 major tertiary care centers. Among 2006 patients with burn who had arrived at collaborating centers between 2004 and 2016, they included patients aged ≥15 years, those who did not present with cardiopulmonary arrest upon arrival, and those who had ≥10 percent total body surface area burns. Patients with missing survival data or unknown mechanism of injury were excluded. In total, 1094 patients were eligible, of whom 222 (20.3 percent) had self-inflicted burns. The patients were divided into the self-inflicted and non-self-inflicted groups, and propensity score was calculated using the demographic information of the patients, injury variables, time from injury to hospital arrival, and other survival predictors. Via a propensity score matching, 98 pairs were selected, and the self-inflicted group had a higher mortality than the non-self-inflicted group (43.9 vs 28.6 percent, hazard ratio = 1.77; 95% confidence interval = 1.10-2.86; P = .02). Inverse probability weighting and multivariate logistic regression were performed as sensitivity analyses, and results validated that self-inflicted burn was independently associated with increased in-hospital mortality. Therefore, patients with self-inflicted burns should receive judicious management, regardless of burn injury severity.

Immigration, Criminal Involvement, and Violence in the U.S.: Results from the National Epidemiologic Survey on Alcohol and Related Conditions-III

Topics of immigration and crime often receive national attention, despite evidence of the "immigrant paradox," in which immigrants have lower than expected crime and violence given their extreme social disadvantage. Research examining the immigrant paradox using an expanded set of crime outcomes and the latest available population data is needed. Using the National Epidemiologic Survey on Alcohol and Related Conditions Wave III data (2012-2013; n = 36,309), we analyzed the association between first-generation immigrant status alongside violence (i.e., other-directed, self-directed, victimization) and criminal involvement (i.e., crime, legal problems, incarceration) outcomes. Immigrants self-reported lower rates of all outcomes compared to U.S.-born adults, providing continued support for the immigrant paradox. Future research considering later generations of immigrants, as well as differential mechanisms through which immigrants and U.S.-born adults engage in violence and crime, is needed.

Challenges Facing Women Survivors of Self-Immolation in the Kurdish Regions of Iran: A Qualitative Study

OBJECTIVES

Women confront many problems after self-immolation, so the purpose of this study was to explore the challenges facing women survivors of self-immolation in the Kurdish Regions of Iran.

METHOD

This study used a qualitative approach and conventional content analysis. Data were collected through semi-structured interviews with 19 Kurdish women who attempted self-immolation in Iran. They were sampled through purposeful sampling and snowball sampling. The Lincoln and Guba criteria were used to strengthen the research.

RESULTS

The results of data analysis were categorized into five main categories: 1-psychological problems, 2-lack of social and legal supportive structures, 3-incomplete treatment, 4-poor self-care, and 5-social problems. These categories consist of 19 subcategories.

CONCLUSION

Having been rescued from self-immolation, the women confront many challenges returning to normal life. Reducing these women's problems and paving the way for their return to life requires multi-dimensional and community-based interventions. Therefore, all social organizations and institutes can cooperate and each of them paves part of the way.

Exploratory analysis of long-term physical and mental health morbidity and mortality: A comparison of individuals with self-inflicted versus non-self-inflicted burn injuries

INTRODUCTION

Self-inflicted burn (SIB) injuries are relatively rare, but patients may experience complex biopsychosocial challenges. This study aimed to compare long-term physical and psychological outcomes for individuals with SIB and non-SIB injuries.

METHODS

Records of adult SIB (n = 125) and non-SIB (n = 3604) injuries were collected from U.S. burn centers within the Burn Model System between 1993 and 2018. Assessments were administered at discharge, 6 months, 24 months, 5 years, and 10 years.

RESULTS

SIB patients were more often younger, unmarried, unemployed, male, struggling with pre-morbid psychiatric issues, and injured by fire/flame (all p < 0.001). SIB injury predicted prolonged mechanical ventilation, hospitalization, and rehabilitation (all p < 0.001). After injury, SIB patients had increased anxiety at 24 months (p = 0.0294), increased suicidal ideation at 5 years (p = 0.004), and clinically worse depression at 10 years (p = 0.0695). SIB patients had increased mortality across 24 months compared to non-SIB patients (OR = 4.706, p = 0.010).

CONCLUSION

SIB injuries are associated with worse physical and psychological outcomes compared to non-SIB injuries including complicated hospitalizations and chronic problems with anxiety, depression, suicidality, and mortality, even when controlling for common indicators of severity such as burn size. This underscores the importance of multidisciplinary treatment, including mental healthcare, and long-term follow-up for SIB patients. Identified pre-morbid risk factors indicate the need for targeted injury prevention.

A study of Kurdish women's tragic self-immolation in Iran: A qualitative study

Self-immolation is one of the most painful methods of suicide which is widespread among women in Kurdish regions of Iran. The present study aimed to explore the causes and sociocultural groundwork of choosing self-immolation methods by women in Kurdish regions of Iran. This present study was conducted using a qualitative approach and conventional content analysis. The research population included women who self-immolated and were rescued in Kurdish regions of Iran. The data collection method was a deep interview as well as observation. The sampling method was based on objective and snowball sampling. The data collection continued to theoretical saturation, the number of participants reached 25 in the end, and Lincoln and Guba criteria were used to strengthen the research. From the analysis of the data obtained in this study, the 8 sub-themes related to cause of suicide attempt from the participants' viewpoints including unbridled coherence, lack of supportive social and environmental structures, economic pressure, aggravation of violence, humiliated ego, dominance of modern values over the local and indigenous ones, incoherent family, and giving up on changing conditions as well as 6 sub themes based on the cause of choosing the method of self-immolation including protesting, frightening the family, catching more attention, championing and showing courage, inducing more guilty feelings in the family and society, fashion or imitation, and easy access were revealed. Self-immolation is one of the most important problems in the Kurdish regions of Iran, which is rooted in various economic, social, psychological and cultural causes. To reduce this social harm, there is a need for comprehensive programs that cover all dimensions.

Timely access to care for patients with critical burns in India: a prehospital prospective observational study

Background

Low/middle-income countries carry a disproportionate burden of the morbidity and mortality from thermal burns. Nearly 70% of burn deaths worldwide are from thermal burns in India. Delays to medical care are commonplace and an important predictor of outcomes. We sought to understand the role of emergency medical services (EMS) as part of the healthcare infrastructure for thermal burns in India.

Methods

We conducted a prospective observational study of patients using EMS for thermal burns across five Indian states from May to August 2015. Our primary outcome was mortality at 2, 7 and 30 days. We compared observed mortality with expected mortality using the revised Baux score. We used Χ² analysis for categorical variables and Wilcoxon two-sample test for continuous variables. ORs and 95% CIs are reported for all modelled predictor variables.

Results

We enrolled 439 patients. The 30-day follow-up rate was 85.9% (n=377). The median age was 30 years; 56.7% (n=249) lived in poverty; and 65.6% (n=288) were women. EMS transported 94.3% of patients (n=399) to the hospital within 2 hours of their call. Median total body surface area (TBSA) burned was 60% overall, and 80% in non-accidental burns. Sixty-eight per cent of patients had revised Baux scores greater than 80. Overall 30-day mortality was 64.5%, and highest (90.2%) in women with non-accidental burns. Predictors of mortality by multivariate regression were TBSA (OR 7.9), inhalation injury (OR 5.5), intentionality (OR 4.7) and gender (OR 2.2).

Discussion

Although EMS rapidly connects critically burned patients to care in India, mortality remains high, with women disproportionally suffering self-inflicted burns. To combat the burn epidemic in India, efforts must focus on rapid medical care and critical care services, and on a burn prevention strategy that includes mental health and gender-based violence support services.

Self-immolation in Iran: Systematic Review and Meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis of self-immolation epidemiology and characteristics in Iran.

METHODS

This was a systematic review and meta-analysis study. PubMed, Scopus, Web of science and Science Direct were searched for English literature and SID and Magiran for Persian in the time period of 2000 to 2016. The retrieved studies were screened and reviewed then quality assessed. Random Effect model was applied for meta-analysis. The qualitative data were analyzed by content analysis method.

RESULTS

After literature screening, 39 studies included in the analysis. Women were subject to self-immolation more than men. The rate of self-immolation estimated to be 4.5 cases in every 100,000 populations and it was the reason of 16% of hospitalized burns. The average length of hospital stay calculated to be 12.24 (95% CI: 8.85-15.59) days. The total burnt surface area was 65.3% (95% CI: 56.71-73.89). Death due to self-immolation was 62.1%. The major risk factors of self-immolation were having mental health issues, family problems and characteristics and problems in relation/communication with spouses.

CONCLUSION

Despite the low rate of self-immolation in Iran, it comprises one sixth of the hospitalized burns. The mortality rate of self-immolation also is high and this highlights the importance of providing special care. Psychological consultations and mental health screening in the primary health care would help to prevent the self-immolation.

Self-burning in Iraqi Kurdistan: proportion and risk factors in a burns unit

To determine the rate of self-burning among all burns patients admitted to the Burns and Plastic Surgery Centre at Sulaimani University in Iraqi Kurdistan and to identify the risk factors and motives, all burns patients, aged 8 years and over, admitted between 1 September 2009 and 30 April 2010 were surveyed. Of the 200 patients interviewed, 54 (27%) reported self-burns and 146 (73%) reported accidental burns. The risk factors for self-burning included mental illness, female gender and younger age. Almost two-thirds of those who reported self-burns (32, 60.4%) had intended to kill themselves. The most commonly cited reasons for the act were family problems (24, 44%) and marital problems (13, 24%). Burns in the self-burning group were more severe and were associated with a higher mortality rate (34, 63%) than in the accidental burns group (29, 20%).

Observations on self-incineration characteristics in 24 years (1993-2016) of autopsies in the city of Milan

Self-incineration is one of the most dramatic and lethal suicide methods. It is rarely reported in Western countries and is more frequent in developing regions. We illustrate the forensic cases of self-immolation occurring over 24 years in the city of Milan, Italy, highlighting the main issues of such a complex and rare suicide. We selected 33 cases of self-incineration among 23,417 autopsies (4022 suicides) performed at the Department of Legal Medicine of the University of Milan over a period of 24 years (1993-2016). Several parameters were included and analysed: gender and age of the victims, pathological history, previous suicide intentions/attempts, duration of burning, place of death or discovery of the corpse, circumstantial data of fatal events and autopsy findings, with particular attention to thermal injuries. Self-incineration was found in 0.8% of total suicides and 0.14% of total autopsies. One of these cases involved a complex modality (association with plastic-bag suffocation). The typical characteristics of the victim were an Italian man with psychiatric illness, frequently moved by passion, existential discomfort and economic problems. During the 24-year period, the number of cases of self-incineration progressively reduced. This study provides a general overview in one of the biggest metropolitan Italian areas and is one of the few works performed on this topic. It may be helpful in understanding and studying such an unusual manner of suicide.

Being Through Doing: The Self-Immolation of an Asylum Seeker in Switzerland

In April 2016, Armin, an asylum seeker in a village of Switzerland, set himself alight in the public square of the town, one of a few cases reported across Europe. He performed the act following a denied request for asylum and was saved by bystanders. We present the results of two qualitative interviews conducted with Armin, his translator and his roommate following the incident. The act is theorized through the lens of a dialogical analysis focusing on the concept of social recognition. The notion of trauma is considered as a key mediating mechanism, theorized as creating ruptures in time, memory, language, and social connections to an Other. We conclude this communicative act to represent both "being-toward-death" and a relational striving toward life; a "destruction as the cause of coming into being."

Creation of Nepal's First Skin Bank: Challenges and Outcomes

Background

In Nepal, burn trauma causes more than 55,000 injuries each year. Burn-related mortality is high in Nepal, in part due to lack of allograft, leading to high infection rates. To address this challenge, our collaboration between Kirtipur Hospital, America Nepal Medical Foundation, Stanford University, and ReSurge International established Nepal's first skin bank.

Methods

We identified 3 major tasks to create a sustainable skin banking program: 1) identify and acquire the equipment and personnel needed to collect, process, store, and graft cadaveric skin for burn injuries; 2) develop safe donation protocols and documentation tools that remain feasible for low-resource settings; and 3) develop a long-term awareness program to educate the Nepali people on skin donation, a previously foreign concept.

Results

Kirtipur Hospital acquired the necessary equipment and materials for the skin bank through a combination of local and international fundraising efforts. Existing U.S. skin banking protocols were adapted for the Nepali setting and piloted on potential patients, donors, and physicians. For the first time in the hospital's history, patients with > 40% total body surface area burns were successfully treated with extensive allografts.

Conclusions

It is feasible to create a skin bank in a country with no tradition of allograft skin use. Long-term sustainability now depends on spreading awareness and education in the Kathmandu Valley to overcome religious and cultural barriers that have hindered donor recruitment. Our low-cost and high-impact skin bank provides a model to expand this system to other hospitals both within Nepal and beyond.

From Querulous to Suicidal: Self-immolation in Public Places as a Symbolic Response to the Feeling of Injustice

Aim: This paper sheds light on the context that leads some querulous patients to self-immolate in front of, or into, public buildings (e.g., tribunals, city halls, and employment agencies). Method: The author defines paranoid querulousness. A psychoanalytic perspective, but also a judicial and a psychiatric point of view, over querulous claimants is presented. The links between political or social claims and self-immolation are studied. The expression of suicidal thoughts voiced by four querulous subjects is analyzed. Eight examples of self-immolation are presented. Results: The querulous subjects' self-aggressive behaviors seem to be caused by a loss of hope to obtain compensation for a prejudice they allegedly suffered. Querulous individuals tend to self-immolate in front of, or into, public buildings when no answer is given to their claims. These gestures may be both a consequence of some personal distress and triggered by a difficult social or professional context. Discussion: Five sets of assumptions derived from Freudian and Lacanian psychoanalytic theories are advanced. The status of the object over which the querulous claimants wish to assert their rights is clarified. The meaning of self-aggressive gestures is outlined by making reference to the concepts of instinct for mastery, symbolic other, chain of signifiers, masochism, pleasure principle, and reality principle. Conclusion: Prevention of self-immolation could involve that members of the legal professions, social workers, civil servants, and mental health professionals in contact with querulous subjects openly show their will to listen to these claimants' voice: self-aggressive gestures might be avoided by supporting the querulous person's hope to obtain compensation for the prejudice allegedly suffered.

Cause-specific mortality among women of reproductive age: Results from a population-based study in an Iranian community

PURPOSE OF STUDY

This study was conducted to evaluate the levels, patterns, and causes of mortality among women of reproductive age in Northwestern Iran.

METHODS

Deaths were determined for females resident in West Azerbaijan Province of Iran and who died between March 2013 to February 2014 using reproductive age mortality survey (RAMOS). Causes of death were ascertained by verbal autopsy (VA) and classified based on the International Classification of Diseases, tenth revision (ICD-10). Overall and cause-specific mortality rates (MRs) per 100,000 women with 95% confidence intervals were calculated.

RESULTS

A total of 510 deaths were detected, and VA interviews were conducted with the relatives of the deceased Cases; overall MR was 56.59 per 100,000 women (95% CI: 56.49-56.69). The highest MR was observed in suicide cases (MR=10.21per 100,000women, 95% CI: 10.15-10.27), accounting for 18% of all deaths. The most common method of suicide was self-inflicted burns (45.6%), followed by deaths due to breast cancer (MR=4.22per 100,000women, 95% CI: 4.18-4.26), which accounted for the most cancer-related mortality. All-cause mortality was associated with age, area of residence, marital status, level of education, and ethnic (religious) status relationship (P<0.001).

CONCLUSION

Suicide, especially self-immolation, was the main cause of death among women of reproductive age, and both suicides and breast cancer are major public health problems for this group of women.

Association Between Burn Injury and Mental Illness among Burn Survivors: A Population-Based, Self-Matched, Longitudinal Cohort Study

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.

A systematic review of burn injuries in low- and middle-income countries: Epidemiology in the WHO-defined African Region

INTRODUCTION

According to the World Health Organization (WHO), burns result in the loss of approximately 18 million disability adjusted life years (DALYs) and more than 250,000 deaths each year, more than 90% of which are in low- and middle-income countries (LMICs). The epidemiology of these injuries, especially in the WHO-defined African Region, has yet to be adequately defined.

METHODS

We performed a systematic review of the literature regarding the epidemiology of thermal, chemical, and electrical burns in the WHO-defined African Region. All articles indexed in PubMed, EMBASE, Web of Science, Global Health, and the Cochrane Library databases as of October 2015 were included.

RESULTS

The search resulted in 12,568 potential abstracts. Through multiple rounds of screening using criteria determined a priori, 81 manuscripts with hospital-based epidemiology as well as eleven manuscripts that included population-based epidemiology were identified. Although the studies varied in methodology, several trends were noted: young children appear to be at most risk; most individuals were burned at home; and hot liquids and flame are the most common aetiologies.

DISCUSSION

While more population-based research is essential to identifying specific risk factors for targeted prevention strategies, our review identifies consistent trends for initial efforts at eliminating these often devastating and avoidable injuries.

Surgical and psychiatric profile of patients who self-harm by burning in a regional burn unit over an 11-year period

Introduction

Patients admitted to hospital for deliberate self-harm by burning (DSHB) provide a challenge for medical, surgical and psychological management. We retrospectively reviewed all the patients admitted to a Scottish regional burn unit with DSHB over an 11-year period to assess demographics and outcome.

Methods

Ward admission data were used to identify DSHB patients admitted to the South East Scotland regional burn unit in Livingston, UK between 2002 and 2012, as well as a control group of accidental burn patients. Data were extracted concerning burn injury, psychiatric history and inpatient management.

Results

A total of 53 DSHB patients with 58 attendances over the 11-year period were compared to 49 accidental burns patients. Compared to controls, DSHB patients were more likely to be unemployed, live alone and have a previous psychiatric diagnosis ( p < 0.01). DSHB patients had more severe burns, a longer hospital stay and were more likely to undergo surgery ( p < 0.01). DSHB patients with previous self-harm, suicide attempts and diagnoses of personality and eating disorder all had significantly less severe burns than DSHB patients without these risk factors ( p < 0.05).

Conclusions

In our experience, DSHB patients have more severe burn injuries and require longer, resource-intensive hospital stays. Burn units should have an appropriate specialist psychologist/psychiatrist who works within the Burn multi-disciplinary team to help manage this complex group of patients’ healthcare needs and reduce their risk of further self-harm.

Suicide: scientific overview and relevance for trauma care providers

The World Health Organization estimates that in the year 2000, approximately one million people died from suicide worldwide. Over the last 45 years, suicide rates have increased by 60%, with a particularly precipitous rise among young people. The underlying psychology of suicide is complex and individual. However, certain themes emerge from studying individuals who have attempted or completed suicides. This paper will provide an overview of suicide and suicidal behaviour as it relates to trauma practitioners, detailing risk factors, biologic and genetic interactions, and opportunities for prevention and treatment.

Paediatric suicidal burns: A growing concern

An alarming rise in rates of paediatric population committing self-immolation acts is a growing social and medical problem. In recent times there seems to be a rising concern in paediatric population. A study was conducted at a government tertiary care burn centre over 5 years in paediatric age group of <18 years who had committed self-immolation. Demographic data, aetiology, burn severity, associated illnesses, treatment and outcomes of the patients were collected with preventive strategies. Of total 89 patients, 12 patients were below 12 years (children) and 77 between 12-18 years (adolescent) with female preponderance. Majority belonged to lower middle and upper lower class families. Most had deep partial thickness burns. Psychiatric and personality disorder were found in 24.03% and 31.46% patients respectively. Kerosene was the main agent chosen to inflict injury. The average length of hospital stay was 19.8 days. The crude mortality rate observed was 38.2%. With cultural and socio-economic changes children and adolescents are exposed to increased levels of stress and peer pressure leaving them vulnerable. A multidisciplinary care involving medical, psychological and social support is required. Identifying children at risk and proper counselling and support can form an important strategy at prevention rather than cure.

Self-inflicted Burns: 10 year review and comparison to national guidelines

INTRODUCTION

There is an increasing trend of self-inflicted burns noted in the literature, often seen in patients with complex psychosocial backgrounds. These patients are challenging to manage as the recovery from the acute burn may be compounded by difficult rehabilitation and suboptimal coping strategies. We aimed to review patients presenting to our burns unit with self-inflicted burns, the management strategies and examine the complexities surrounding their management. We assessed patient outcomes with a particular interest in psychosocial support given.

METHODS

A retrospective review of all patients presenting with self-inflicted burns over a 10 year period (2005-2014 inclusive) was conducted. Patients were identified through IBID database coded as either 'self-inflicted' or 'suicidal.' We reviewed patient and burn demographics, the clinical management, psychosocial management and patient outcomes such as wound healing, re-admission rates, and survival.

RESULTS

We identified 118 self-inflicted burns in total. 50/118 (42%) were admitted. 64 (54%) were male and the total body surface burn area ranged from <0.5% to 99% with a median of 14%. 60/118 (51%) had TBSA <10% and 58/118 (49%) had TBSA >10%. 24 (48%) underwent admission to the Burn Intensive Care Unit (BITU). All patients admitted to BITU had TBSA >10%. Of those admitted to BITU 6 were palliative, 18 had full resuscitation and surgical management. Of those 18 patients who had active treatment, 10/18 (56%) died. Mean total length of stay was 31 days, range 1-130 days. 9% of patients sustained injuries whilst being a current inpatient at a psychiatric institution. Of all patients reviewed, 16% (n=19) had a previous history of deliberate self-harm through burns. Of those patients admitted, 98% of were reviewed by the mental health team during their admission with time to psychological review varying depending on fitness for assessment. The overall mean length of stay for all admitted patients who were actively treated but who subsequently died was 53 days. 84% of admitted patients were managed surgically.

CONCLUSION

Self-inflicted burns patients would benefit from a more complex pathway of treatment as their management aims to achieve not only physical health but also psychological health. They would benefit from enhanced care to manage the acute burn but also psychiatric support to ensure patients do not re-offend.

Two decades of adolescent suicides assessed at Milan University's medicolegal unit: Epidemiology, forensic pathology and psychopathology

AIM

to analyze the cases of suicide committed by adolescents in and around the city of Milan over a 20-year period (1993-2012).

MATERIALS AND METHODS

cases of suicide involving individuals between 10 and 19 years of age were drawn from 20,757 autopsies performed by the Medico-legal Unit at Milan University. Seventy-eight cases were considered (20 females and 58 males, with the ratio of 1:2.9), and their clinical and circumstantial histories, epidemiology, forensic pathology and psychopathological issues were analyzed.

RESULT

Adolescents were involved in 2.23% of all suicides committed in Milan during the period examined. The "mean" victim is a male without psychiatric disease, aged between 16 and 19, that commits suicide outdoors.

CONCLUSIONS

In the majority of cases, there were no premonitory signs, nor any particular contingent or remote reason that might explain these violent deaths, which therefore remain "impulsive".

Intentional burns in Nepal: a comparative study

AIMS

Intentional burns injuries are associated with high mortality rates, and for survivors, high levels of physical and psychological morbidity. This study provides a comprehensive assessment of intentional burn admissions to the adult Burns Unit at Bir Hospital, Kathmandu, Nepal, during the period 2002-2013.

METHODS

A secondary data analysis of de-identified data of patients hospitalized at Bir Hospital, Kathmandu, with a burn during the period of 1 January 2002 to 31 August 2013. Socio-demographic, injury and psychosocial factors of patients with intentional and unintentional burns are described and compared. Chi-square tests, Fisher's exact test and Wilcoxon rank sum tests were used to determine statistical significance.

RESULTS

There were a total of 1148 burn admissions of which 329 (29%) were for intentional burn, 293 (26%) were self-inflicted and 36 (3%) were due to assault. Mortality rates for intentional burns were approximately three times those for unintentional burns (60 vs. 22%). When compared to unintentional burns, patients with intentional burns were more likely to be female (79 vs. 48%), married (84 vs. 67%), younger (25 vs. 30 years), have more extensive burns (total body surface area, %: 55 vs. 25) and higher mortality (60 vs. 22%). Intentional burns were more likely to occur at home (95 vs. 67%), be caused by fire (96 vs. 77%), and kerosene was the most common accelerant (91 vs. 31%). A primary psychosocial risk factor was identified in the majority of intentional burn cases, with 60% experiencing adjustment problems/interpersonal conflict and 32% with evidence of a pre-existing psychological condition. A record of alcohol/substance abuse related to the patient or other was associated with a greater proportion of intentional burns when compared with unintentional burns (17 vs. 4%).

CONCLUSIONS

The majority of intentional burn patients were female. Almost all intentional burns occurred in the home and were caused by fire, with kerosene the most common accelerant used. Underlying psychosocial risk factors were identified in most cases. Intentional burns resulted in severe burns with high mortality. Intentional burns are not only a serious medical issue; they represent significant public health and gender issues in Nepal.