Epidemiology of burns throughout the World. Part II: intentional burns in adults

Exploring misclassification of injury intent: A burn register study

INTRODUCTION

Burn registers are an important source of surveillance data on injury intent. These data are considered essential to inform prevention activities. In South Asia, intentional burn injuries are thought to disproportionately affect women. Assessment of injury intent is difficult because it is influenced by personal, family, social, and legal sensitivities. This can introduce misclassification into data, and bias analyses. We conducted a descriptive, hypothesis generating study to explore misclassification of injury intent using data from a newly digitised single centre burn register in south India.

METHODS

Data from 1st February 2016 to 28th February 2022 were analysed. All patients in the data set were included in the study (n = 1930). Demographic and clinical characteristics for patients are described for each classification of injury intent. All data cleaning and analyses were completed using RStudio.

RESULTS

Injury intent data were missing for 12.6% of cases. It was the most commonly missing variable in the data set. "Accidental" injuries had a similar distribution over time, age, and total body surface area (TBSA) for males and females. "Homicidal" injuries were more common in females. Injuries reported as "Suicidal" affected men and women equally. A decrease in reporting of "Suicidal" injuries in females corresponded to an increase in high TBSA injuries classified as 'Other' or with missing data. Overwriting of injury intent was present in 1.5% of cases. The overwritten group had a greater proportion of females (62.1% vs. 48.5%) and higher median TBSA (77.5% vs. 27.5%) compared to the group where intent was not overwritten.

CONCLUSION

Our findings indicate that some subgroups, such as females with high TBSA burns, appear to be more likely to be misclassified and should be the focus of future research. They also highlight that quality of surveillance data could be improved by recording of clinical impression, change in patient reported intent, and use of a common data element for intent to standardise data collection. We also recommend that injury intent is recorded as a unique variable and should not be mixed with other elements of injury causation (e.g. mechanism). Although this is a single centre study, the methods will be of interest to those who utilise routinely collected data and wish to reduce misclassification of this important variable.

Self-inflicted burns in Brazil: systematic review and meta-analysis

INTRODUCTION

burns represent a pivotal component of trauma in Brazil, accounting for 2 million incidents and 2,500 deaths annually. Self-intentional burns are associated with a worse prognosis, larger burned surface area, higher infection rates, and death. The lack of studies on the issue of self-immolation raises epidemiological questions regarding Brazilian victims. This study aimed to investigate the profile of burn events associated with self-injurious behavior among Brazilian victims.

METHODS

this systematic review was performed according to PRISMA 2020 guidelines and evaluated the correlation between self-injurious behavior as a cause of burns in Brazilian victims and its epidemiological implications in the last 20 years (2003-2023). The MeSH terms "Burns", "Self-Injurious Behavior", "Epidemiology" and "Brazil" were queried in the PubMed/MEDLINE, SciELO, and Cochrane Library databases, and, after selection by inclusion/exclusion criteria, the most relevant studies were critically analyzed.

RESULTS

From 1,077 pre-selected studies, 92 were potentially eligible, resulting in 7 manuscripts incorporated in this review. From 3,510 burned victims assembled in the pool of selected studies, 311 cases displayed self-injurious behavior. Burned patients who attempted to burn their lives have a higher risk of death (p<0.05; RR=5.1 [3.2-8.1]) and larger burned surface area (p<0.05; MD=19.2 [10-28.2]), compared to accidental cases. Moreover, the female gender was at a higher risk of attempting self-immolation (p<0.05; RR=4.01 [2.9-5.5]).

CONCLUSION

our results show that self-inflicted burn cases were associated with a larger burned surface area and a higher risk of death, and the female gender was identified as a relevant risk factor in Brazil.

Epidemiology of Burn Injuries Among Adult Females in Southern Iran; A Retrospective Study from 2007 to 2022

Burn-by flame, flush, scald, electrical, and chemical types-accounts for 5%-12% of trauma injuries worldwide. In Iranian studies, females were the main victims of domestic burns with higher mortality and frequencies. This retrospective study evaluates the epidemiology and etiology of burn injuries in females aged 25-64 years between October 2007 and May 2022 in southern Iran. Demographics and burn etiology information were collected by questionnaires at admission. Univariate and multivariate regression analysis was used to determine the relationship between variables and burn mortality. Pearson's Chi-Square and One-way ANOVA tests were utilized to compare different burn etiologies. Of 3212 females with burn injuries, 1499 (46.6%) were included with a mean age of 38.5 ± 10.8 years. Flame (59.7%) and flush (28.9%) were significantly the most common injuries mechanism. Burn was most common in rural areas (53.9%) and indoor settings (62.1%) (P-value < .001). 77.9% of the population were under-diploma (P-value < .001), and 3.5% were divorced with higher burn-suicide attempts. The mean Total Body Surface Area (TBSA%) was 41.1 ± 28.3%, and the mean Length of Stay (LOS) was 14.5 ± 13.2 days with a 39.1% mortality rate. With univariate and multivariate analysis, TBSA%, indoor places, flame, flush, and urban living were risk factors for burn mortality. Briefly, flame in indoor settings is the most common type of burn injury affecting adult females with lower educational levels living in rural areas. Such epidemiological studies of burns in adult females may be helpful for health policymakers to develop burn prevention programs.

Microbial infections in burn patients

Polymicrobial infections are the leading causes of complications incurred from injuries that burn patients develop. Such patients admitted to the hospital have a high risk of developing hospital-acquired infections, with longer patient stays leading to increased chances of acquiring such drug-resistant infections. Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Proteus mirabilis are the most common multidrug-resistant (MDR) Gram-negative bacteria identified in burn wound infections (BWIs). BWIs caused by viruses, like Herpes Simplex and Varicella Zoster, and fungi-like Candida spp. appear to occur occasionally. However, the preponderance of infection by opportunistic pathogens is very high in burn patients. Variations in the causative agents of BWIs are due to differences in geographic location and infection control measures. Overall, burn injuries are characterized by elevated serum cytokine levels, systemic immune response, and immunosuppression. Hence, early detection and treatment can accelerate the wound-healing process and reduce the risk of further infections at the site of injury. A multidisciplinary collaboration between burn surgeons and infectious disease specialists is also needed to properly monitor antibiotic resistance in BWI pathogens, help check the super-spread of MDR pathogens, and improve treatment outcomes as a result.

Development of an electronic burns register: Digitisation of routinely collected hospital data for global burns surveillance

INTRODUCTION

Burn registers provide important data that can track injury trends and evaluate services. Burn registers are concentrated in high-income countries, but most burn injuries occur in low- and middle-income countries where surveillance data are limited. Injury surveillance guidance recommends utilisation of existing routinely collected data where data quality is adequate, but there is a lack of guidance on how to achieve this. Our aim was to develop a rigorous and reproducible method to establish an electronic burn register from existing routinely collected data that can be implemented in low resource settings.

METHODS

Data quality of handwritten routinely collected records (register books) from a tertiary government hospital burn unit in Mysore, India was assessed prior to digitisation. Process mapping was conducted for burn patient presentations. Register and casualty records were compared to assess the case ascertainment rate. Register books from February 2016 to February 2022 were scanned and anonymised. Scans were quality checked and stored securely. An online data entry form was developed. All data underwent double verification.

RESULTS

Process mapping suggested data were reliable, and case ascertainment was 95%. 1930 presentations were recorded in the registers, representing 0.84% of hospital all-cause admissions. 388 pages were scanned with 4.4% requiring rescanning due to quality problems. Two-step verification estimated there to be errors remaining in 0.06% of fields following data entry.

CONCLUSION

We have described, using the example of a newly established electronic register in India, methods to assess the suitability and reliability of existing routinely collected data for surveillance purposes, to digitise handwritten data, and to quantify error during the digitisation process. The methods are likely to be of particular interest to burn units in countries with no active national burns register. We strongly recommend mobilisation of resources for digitisation of existing high quality routinely collected data as an important step towards developing burn surveillance systems in low resource settings.

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

INTRODUCTION

A key component in the classification of all injury types is to differentiate whether the injury was deliberately inflicted and by whom, commonly known as "intent" in the surveillance literature. These data guide patient care and inform surveillance strategies. South Asia is believed to have the greatest number of intentional burn injuries, but national surveillance data is not disaggregated by injury intent. Scientific literature can be used for injury surveillance where national data collection does not exist. In order to synthesise research findings, it is essential to assess the potential impact of misclassification bias. We therefore conducted a systematic scoping review to understand terminology and methods used to differentiate injury intent of hospital burn patients in South Asia.

METHODS

We followed the methods in our registered protocol (https://doi.org/10.17605/OSF.IO/DCYNQ). Studies met defined population, concept, context, and study design criteria. The databases Embase, MEDLINE, CINAHL, PsycInfo, and PakMediNet were searched. Two reviewers independently screened results. Data were extracted in a standardised manner and verified. The rigour of the method used to differentiate injury intent was appraised.

RESULTS

1435 articles were screened. Of these, 89 met our inclusion criteria. Most articles were from India and Pakistan, and used an observational study design. There were 14 stem terms used in the articles. The most common was "cause". There were 40 classifier terms. The most common were "accident", "suicide", and "homicide". Few articles defined these terms. The method used to differentiate injury intent was only described explicitly in 17% of articles and the rigour of the methods used were low. Where methods of differentiation were described, they appear to be based on patient or family report rather than multidisciplinary assessment.

CONCLUSION

The heterogeneity in terms, lack of definitions, and limited investigation of injury intent means this variable is likely to be prone to misclassification bias. We strongly recommend that the global burn community unites to develop a common data element, including definitions and methods of assessment, for the concept of burn injury intent to enable more reliable data collection practices and interstudy comparisons.

Spectrum of vitriolage in India: A retrospective data record-based study

Introduction

Vitriolage or acid attack or acid throwing is a gender-based terrible violent crime. There are many everlasting sequels of vitriolage which consist of permanent scarring of the face or body, blindness as well as socioeconomic and psychological intricacy. The sufferer of acid attack is competitor, hatred, enmity or jealousy. Vitriolage are most common in the Asian countries especially in south east Asian region followed by Europe and South America. Bangladesh, India, Pakistan, Colombia and Cambodia are the countries having the highest incidence of acid attacks. There is a sharp rise in vitriolage cases in India in the last few years as indicated by data from the National Crime Record Bureau (NCRB). Seventy per cent victims of vitriolage are women in India as indicated by the annual reports of the Acid Survivor Foundation.

Aims and Objective

The aim of the study was to report incidence of acid attacks in India, Indian states and metropolitan cities. To analyse various police and court procedure and to discuss various steps to give justice to the victim of vitriolage.

Materials and Methods

Present study is a retrospective data record-based study. Available data for the last 5 years (from 2017 to 2021) were taken from National Crime Report Bureau (NCRB). Available as per NCRB, data were analysed as per aims and objectives.

Results

The trend of incidence of acid attacks in India was decreasing in the last 5 years, that is, the incidence was 244 in the year 2017 which become 176 in the year 2021. West Bengal and Uttar Pradesh were the states having the highest number of acid attack incidence during the last 5 years. Delhi city was the top most metropolitan city having the highest acid attack incidence in the last 5 years. Police investigation of cases of acid attacks against women and cases disposed of by the police decreased in the last 5 years. The chargesheeting rate was better in metropolitan cities than overall chargesheeting in India. There was an increased trial of cases of acid attacks against women and a decrease in cases disposed of by the court during the last 5 years. Conviction rate by the court was better in India than the metropolitan cities of India during the last 5 years. Case acquitted by the court in India was 24, 9, 10, 4 and 10, and in metropolitan cities it was 2, 1, 3, 0 and 2 during year 2017, 2018, 2019, 2020 and 2021, respectively.

Conclusion

Vitriolage not only destroys physical health but also destroys mental health. Despite of strict action taken by the Indian government, vitriolage is still prevalent in India. Male dominancy and inadequate legal systems are responsible for this. Though there is a standard set by the Supreme Court for the sale of acid, it remains easily available as the guidelines are frequently violated by the preparator. Case investigation and chargesheeting should increase by the police. Trial of the case and conviction should increase by the court. Vitriolage victims must be sure of their scope to obtain education and job opportunity and societal fiction should be reviewed to support people to acknowledge why vitriolage is committed mainly against females.

Effects of a Spiritual Care Program on Body Image and Resilience in Patients with Second-Degree Burns in Iran

This research was conducted with the aim of investigating the effect of a spiritual care program (SCP), on the body image and resilience of second-degree burn patients in Iran. In this semi-experimental study, 60 patients with second-degree burns were selected in the Tehran Mottahari Burns Hospital, Iran in 2022. These patients were divided through random allocation into two intervention and control groups. The patients of both groups filled out Beck's self-esteem Test (BSCT) and Connor-Davidson Resilience Scale (CD-RISC) before, immediately, and 3 months after the intervention. In the intervention group, SCP was performed for eight sessions over two weeks. Firstly, the 4D Model of Spiritual Health and Well-Being was examined, then two one-hour sessions were held with each patient about each dimension, with a total of four dimensions including eight sessions, in which these dimensions were examined and discussed. There was no difference in the score of body image (P = 0.326) and resilience (P = 0.597) before intervention in the control and intervention groups. However, the mean of body image score in the intervention group immediately (109.56 ± 4.86) and 3 months after (109.16 ± 6.06) the intervention was significant, respectively. Also, the mean of resilience score in the intervention group was significant immediately (85.86 ± 6.78) and 3 months after the intervention (85.73 ± 6.27). It is suggested for healthcare providers to use the SCPs to reduce the recovery time of burned patients and reduce complications and treatment costs.

Clinical profile, management and risk factors for seizure-related burn injuries among patients with epilepsy in southwest China

Objective

The epidemiological information associated with seizure-related burn injuries is lacking in China. Therefore, this study aims to analyze the clinical profile, management, outcome, and risk factors of burns that are directly caused by seizures among epileptic patients, and identify the epidemiological characteristics to develop effective preventive strategies.

Methods

This study was conducted between January 2002 and December 2022 in a large Chinese burn center. Data including clinical profile, wound treatment, and outcome were analyzed. A multiple linear regression was used to screen the risk factors for the length of hospital stay (LOS), and a multiple logistic regression was used to screen the contributory factors for the amputation.

Results

A total of 184 burn patients (55.98 % females) were enrolled, with a 0.78 % incidence rate during the study period. The mean age of the patients was 36.16 years (SD: 17.93). Patients aged 20-29 were the most affected age groups (23.37 %). Most burns were caused by flame, accounting for 60.33 % (111/184) of all cases. In total, 76.09 % of the 184 patients underwent at least one operation, and 35 patients (19.02 %) still required amputation during the study period. Burn sites (hands) had the greatest impact on amputation (OR = 3.799), followed by flame burns (OR = 3.723). The mean LOS/TBSA was 6.90 ± 8.53 d, and a larger TBSA, full-thickness burns, and a higher number of operations were identified as the risk factors for a longer LOS. There was one death among the 184 patients, with a mortality rate of 0.54 %.

Conclusion

This study demonstrates that burn injuries are extremely harmful to individuals with epilepsy in China because they are at high risk of amputation and disability. Effective healthcare education and preventive programs that focus on lifestyle modifications and seizure control should be implemented to reduce the burn incidence in these populations.

Self-inflicted Burns: The Experience of a UK Regional Burns Center

Self-inflicted burns (SIBs) are preventable injuries that often occur due to suicidal intent or deliberate self-harm. The incidence of SIB and demographics vary across different countries. This study highlights our regional experience of SIB over almost 2 decades, assessing characteristics and outcomes. A retrospective chart review of all patients assessed at a UK regional burns center, presenting with SIB, from 2003 to 2021, was performed. Subgroup analyses based on gender, the presence or absence of pre-existing psychiatric disorders, and in-hospital patient mortality were undertaken. The relationship between annual mental health funding and the incidence of SIB was assessed. Over the study period, a total of 285 SIB cases, with a median age of 42.84 years, were presented to our center. The majority of patients were male (63.2%) and had a pre-existing psychiatric disorder (74.7%). Flame burns were the most frequent type of injury (82.1%) and the median total BSA (TBSA) was 10.25%. The average length of hospital stay was 10 days and the inpatient mortality rate was 20.7%, significantly greater than the mortality of the rest of the cohort (3.7%, P < .01). SIB survivors were younger and had less severe burns, relative to non-survivors. There was no statistically significant correlation between the incidence of SIBs and mental health funding. SIBs account for a minority of referrals to our regional burns center. Adequately funded regional and national measures should be implemented to reduce the incidence and impact of these injuries, alongside appropriate mental health support.

Exploring the wound-healing and antimicrobial potential of Dittrichia viscosa L lipidic extract: Chemical composition and in vivo evaluation

Dittrichia viscosa belongs to the Dittrichia genus, it grows abundantly in the east and northeast of Morocco, and traditionally its fresh leaves are crushed and given for topical application after burns, wounds, and infections. In this study, we examine the wound-healing activity of Dittrichia viscosa lipidic extract in vivo, assess its anti-microbial effect, and explore the specific compounds that contribute to these effects. To assess the effectiveness of wound healing, a burn-induced wound model was employed in Wistar rats, and the levels of hydroxyproline as well as histopathological changes in the skin tissues were evaluated. Furthermore, the antimicrobial potential against Bacillus subtilis, Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Candida albicans, Candida glabrata, and Malassezia furfur was investigated using the agar disc diffusion method. Gas Chromatography-mass spectrometry (GC-MS) and high-performance liquid chromatography (HPLC) techniques were employed to analyze the composition of fatty acids, phytosterols, and tocopherols. Topical application of Dittrichia viscosa lipidic fraction ointment exhibited significant improvements in wound contraction, achieving an impressive rate of 82% within 21 days. Additionally, the lipidic extract of Dittrichia viscosa displayed notable efficacy against various microbial strains, including Candida albicans (25.07 ± 0.2), Candida glabrata (24 ± 0.6), and Malassezia furfur (22 ± 0.7). The primary fatty acids identified in the sample were linolenic acid (58.95% ± 0), oleic acid (16.75% ±0.04), and linoleic acid (11.97% ± 0.1). Notably, the sample contained significant amounts of γ-Tocopherols (732.08 ± 21mg/kg), while the sterol fraction primarily consisted of 7-Campesterol (1937 ± 0 mg/kg), 7-β-Sitosterol (1621 ± 0 mg/kg), and Stigmasterol (1439 ± 26 mg/kg). By its richness in active compound content, Dittrichia viscosa effectively accelerates wound healing while safeguarding against microbial infections.

In-hospital Mortality Following Suicidal Burns: A Propensity Score-Matched Analysis

We carried out a retrospective single-center study and analyzed all patients who have been admitted to our intensive care burn unit following suicide attempt and accidental burns within 14 years. Clinical and demographic parameters were collected and evaluated. Propensity score matching was performed in order to minimize the confounding effect of the parameters age, sex, total body surface area (TBSA), and the presence of full-thickness burns and inhalation injury. 45 burn patients following attempted suicide by burning and 1266 patients following accidental burn injury were admitted. Patients with suicidal burn injuries were significantly younger and showed significantly higher burn severity, reflected by larger TBSA affected, higher incidence of full-thickness burns and inhalation injury. They also experienced increased hospital length of stay (LOS) and longer ventilation durations. Their in-hospital mortality was significantly higher. Following propensity score matching in 42 case pairs, no differences were detected with regard to in-hospital mortality, hospital LOS, duration of mechanical ventilation, and frequency of surgical interventions. Attempted suicide by burning is associated with overall worse outcomes and higher mortality rates. Following propensity score matching, significant differences in outcomes were no longer detectable. Given the comparable survival probability compared to accidentally burned patients, life-sustaining treatment should not be withheld in burn patients following suicide attempt.

Psychological Issues

Psychological distress is common following a burn injury, and many burn survivors have pre-morbid psychiatric illnesses including mood and trauma-related disorders, and substance and alcohol use. This article is intended to be used by all interdisciplinary health care team members to improve the identification and treatment of common psychological concerns experienced by survivors and is organized to follow the general recovery timeline.

Severe Burns of the Genital Area After Laser Hair Removal: A Case Report

Burn injuries are among the most commonly observed complications of laser hair removal. Here, we present a case, in which severe massive burns were caused in the genital and perineal areas during such a procedure. The consequent scar formation led not only to negative aesthetic effects but also affected the physical and psychological health of the patient.

A systematic review of medical science students' knowledge and related factors towards burns first aids

This systematic review aims to examine the knowledge of medical science students about burn first aid. A comprehensive, systematic search was performed in different international electronic databases, such as Scopus, PubMed, Web of Science, and Persian electronic databases such as Iranmedex, and Scientific Information Database (SID) using keywords extracted from Medical Subject Headings such as "Knowledge", "First aid", "Medical science student" and "Burn" from the earliest to February 1, 2023. The quality of the studies included in this systematic review was evaluated by using the appraisal tool for cross-sectional studies (AXIS tool). Thirteen studies had a total of 5046 students studying medical sciences. Among them, 62.24% were female and 77.67% were medical students. The studies included in this systematic review were conducted in Saudi Arabia, Pakistan, Syria, Egypt, and Malaysia. Medical science students' average knowledge of first aid for burns is 56.92 out of 100, which is considered to be a moderate level of knowledge. Factors such as the experience of first aid training, academic year, clinical experience, and economic status had a significant positive relationship with the knowledge of medical science students about first aid for burns. Also, factors such as age, academic specialisation, academic year, information sources, and fathers' occupation had a significant relationship with the knowledge of medical students about first aid for burns. Therefore, it is suggested that healthcare managers and policymakers make the necessary plans to ensure that first aid training courses are implemented during medical science students' studies as a part of their curriculum.

Photographic Evaluation of Burn Depth via Telemedicine: Insights from Iranian Surgeons

Background

The accurate assessment of burn depth is crucial for determining appropriate treatment. Telemedicine has emerged as a promising tool for supporting burn diagnosis and decision-making, as it allows for remote consultation with burn specialists and access to high-quality imaging. The aim of this study was to evaluate the diagnostic capabilities of telemedicine in diagnosing burn depth.

Methods

A total of 15 Iranian surgeons participated in this study; they were presented with 13 images of partial thickness burn ulcers located on the extremities and trunk of patients. The participating surgeons were required to provide their diagnoses of burn type and depth, as well as the necessity of surgical intervention, and their responses were recorded.

Results

Data from 11 participants and 143 responses were analyzed. The average diagnostic accuracy for superficial burns was 79.3%, while for deep burns, it was 13.72%. The mean total diagnostic accuracy was 75.2%.

Conclusion

The results of this study suggest that photographs can be a reliable diagnostic tool for evaluating superficial burns. However, photographs are neither valid nor reliable for assessing burn depth. These findings have important implications for the use of telemedicine in burn diagnosis and indicate that additional diagnostic tools may be necessary for accurate assessment of deep burns.

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 ).

Violence by Burning Against Women and Girls: An Integrative Review

Violence against women and girls by burning is a serious and confronting form of gender-based violence. Often, perpetrators aim to disfigure their victims or cause great pain, rather than kill them. Little is known about the characteristics of females who are subjected to violence by burning. This study aimed to review the literature concerning the prevalence, demographic profile, injury event, contributing factors and health outcomes for women and girls who have experienced burn-related violence. A search across five databases (PubMed, CINAHL, PsycINFO, Scopus and LILACS) was conducted up to April 2021 to identify original peer-review research, with a focus on violence by burning against women and girls. The review was guided by the five-stage approach to integrative reviews developed by Whittemore and Knafl (2005). Fifteen studies were identified. Victims were predominantly married, with low socio-economic status, limited education, and high emotional and financial dependency on their partners or families. Burn injuries were mostly caused by flame or acid, with significant morbidity or high mortality. Motives included family/marital issues or property/financial disputes. This review identified the limited evidence available in the peer-reviewed literature related to burn-related violence against women and girls worldwide. Findings suggest the need for further research to provide a clearer understanding of the complex issues involved.

Challenges of nurses and family members of burn patients: Integrative review

AIMS

To identify the challenges facing burn care nurses and burn patients' family members and to explore the relationship between the above challenges.

DESIGN

Whittemore and Knafl's integrative review.

METHODS

Databases used for this review included Cochrane Library, Web of Science, PubMed and Embase. The original research published from January 2010 to November 2021 was selected. Studies reporting the challenges of family members or nurses of burn patients identified through extensive database search were considered for inclusion. The Mixed-Method Appraisal-Tool was applied for the evaluation of the quality of the literature. The analysis approach used was content analysis.

RESULTS

Of the 2746 identified studies, 17 studies were included. Key findings related to the challenges facing nurses and family members of burn patients were extracted. The themes relating to burn care nurses included ethical and religious issues, clinical issues, work-life imbalance and limited support. The themes relating to family members included family's different views on prognosis and treatment, work-life imbalance, psychological issues and lack of multifaceted support. The challenges for the formal and informal caregivers are similar and there is existence of some shared concerns. If the above challenges are not resolved, support for the burn patients may be adversely affected. Corresponding measures should be taken to overcome such challenges.

Establishing Self-Harm Registers: The Role of Process Mapping to Improve Quality of Surveillance Data Globally

Self-harm registers (SHRs) are an essential means of monitoring rates of self-harm and evaluating preventative interventions, but few SHRs exist in countries with the highest burden of suicides and self-harm. Current international guidance on establishing SHRs recommends data collection from emergency departments, but this does not adequately consider differences in the provision of emergency care globally. We aim to demonstrate that process mapping can be used prior to the implementation of an SHR to understand differing hospital systems. This information can be used to determine the method by which patients meeting the SHR inclusion criteria can be most reliably identified, and how to mitigate hospital processes that may introduce selection bias into these data. We illustrate this by sharing in detail the experiences from a government hospital and non-profit hospital in south India. We followed a five-phase process mapping approach developed for healthcare settings during 2019-2020. Emergency care provided in the government hospital was accessed through casualty department triage. The non-profit hospital had an emergency department. Both hospitals had open access outpatient departments. SHR inclusion criteria overlapped with conditions requiring Indian medicolegal registration. Medicolegal registers are the most likely single point to record patients meeting the SHR inclusion criteria from multiple emergency care areas in India (e.g., emergency department/casualty, outpatients, other hospital areas), but should be cross-checked against registers of presentations to the emergency department/casualty to capture less-sick patients and misclassified cases. Process mapping is an easily reproducible method that can be used prior to the implementation of an SHR to understand differing hospital systems. This information is pivotal to choosing which hospital record systems should be used for identifying patients and to proactively reduce bias in SHR data. The method is equally applicable in low-, middle- and high-income countries.

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.

Vacuum and Electromagnetic Fields Treatment to Regenerate a Diffuse Mature Facial Scar Caused by Sulfuric Acid Assault

Acid attacks are on the rise, and they cause extensive and deep burns, especially on the face. The treatments used to improve the aesthetic, functional and social impact of non-acid scars do not always prove useful for acid scars. This article reports the case of a woman with an extended, mature, acid facial scar, caused by sulfuric acid assault, treated with a recent new procedure that combines the application of vacuum and electromagnetic fields. Before and after the treatment, the aesthetic appearance, and motor function of the face and neck were evaluated, as well as the level of hydration, the amount of sebum, the elasticity, and the pH of the skin. The improvements highlighted after the treatment of the aesthetic and functional characteristics of the face and neck, and of the physical parameters of the skin seemed to indicate that this particular treatment induces tissue regeneration, even in the nerve component. However, it is evident that the rehabilitation pathways of facial wounds and scars must be personalized, and must include continuous psychological support for the patient.

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.

A Randomized Trial of Enteral Glutamine for Treatment of Burn Injuries

BACKGROUND

Glutamine is thought to have beneficial effects on the metabolic and stress response to severe injury. Clinical trials involving patients with burns and other critically ill patients have shown conflicting results regarding the benefits and risks of glutamine supplementation.

METHODS

In a double-blind, randomized, placebo-controlled trial, we assigned patients with deep second- or third-degree burns (affecting ≥10% to ≥20% of total body-surface area, depending on age) within 72 hours after hospital admission to receive 0.5 g per kilogram of body weight per day of enterally delivered glutamine or placebo. Trial agents were given every 4 hours through a feeding tube or three or four times a day by mouth until 7 days after the last skin grafting procedure, discharge from the acute care unit, or 3 months after admission, whichever came first. The primary outcome was the time to discharge alive from the hospital, with data censored at 90 days. We calculated subdistribution hazard ratios for discharge alive, which took into account death as a competing risk.

RESULTS

A total of 1209 patients with severe burns (mean burn size, 33% of total body-surface area) underwent randomization, and 1200 were included in the analysis (596 patients in the glutamine group and 604 in the placebo group). The median time to discharge alive from the hospital was 40 days (interquartile range, 24 to 87) in the glutamine group and 38 days (interquartile range, 22 to 75) in the placebo group (subdistribution hazard ratio for discharge alive, 0.91; 95% confidence interval [CI], 0.80 to 1.04; P = 0.17). Mortality at 6 months was 17.2% in the glutamine group and 16.2% in the placebo group (hazard ratio for death, 1.06; 95% CI, 0.80 to 1.41). No substantial between-group differences in serious adverse events were observed.

CONCLUSIONS

In patients with severe burns, supplemental glutamine did not reduce the time to discharge alive from the hospital. (Funded by the U.S. Department of Defense and the Canadian Institutes of Health Research; RE-ENERGIZE ClinicalTrials.gov number, NCT00985205.).

The epidemiological characteristic and trends of burns globally

Background

Burns is a type of injury, caused by unintentional exposure to substances of high temperature, including hot liquid, solid, and objects radiating heat energy, placing a high burden not only on patients’ families but also on national healthcare systems globally. It is difficult for policymakers and clinicians to formulate targeted management strategies for burns because data on current epidemiological patterns worldwide are lacking.

Methods

Data on burns were obtained from the Global Burden of Disease (GBD) 2019 Study. The incidence, disability-adjusted life years (DALYs), and deaths of burns in 204 countries and regions from 1990 to 2019 were calculated and stratified by sex, age, geographical location, and sociodemographic index (SDI). The estimated annual percentage change (EAPC) of incidence, DALYs, and deaths was calculated to evaluate the temporal trends. All analyses were performed using R software, version 4.1.1, with 2-sided P-values < .05 indicating a statistically significant difference.

Results

A total of 8,378,122 new cases (95% UI, 6,531,887–10,363,109cases) of burns were identified globally in 2019, which is almost evenly split between men and women, and most of the new cases were concentrated in the 10–19-year age group. Besides, burns account for 111,292 deaths (95% UI, 132,392–88,188) globally in 2019, most of which were concentrated in those aged 1–4 years. The burden of burns measured in DALYs was 7,460,448.65 (95% UI, 5,794,505.89–9,478,717.81) in 2019, of which 67% and 33% could be attributed to YLLs and YLDs, respectively. The EAPC of incidence, DALYs, and deaths were negative, the age-standardized rate (ASR) of incidence, DALYs, and deaths were considered to be decreasing in most of the regions, and the EAPCs were negatively correlated with SDI levels, universal health coverage (UHC), and gross domestic product (GDP).

Conclusion

Globally, the age-standardized rates of burn incidence, DALYs, and mortality, as well as the number of burn DALYs and death cases will continuously decrease, but the number of new burn cases has an increasing tendency globally. In addition, the EAPCs of burns in incidence, DALYs, and deaths indicated that the burden of burns was considered to be decreasing in most of the regions. And from the relationship of EAPCs with SDI, UHC index, and GDP, indicate that prevention burns not only depend on health spending per capita but also depend on the education level per capita and healthcare system performance, but it does not mean higher health spending corresponds to higher UHC index, which needs high efficiency of translating health spending into individuals health gains.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13887-2.

Increased self-immolation frequency and severity during the COVID-19 pandemic

OBJECTIVE

To determine whether the increased restrictions, isolation and stressors associated with COVID-19 led to an increase in rates or severity of self-immolation burn injuries.

DESIGN

Retrospective review of a prospectively-collected database of New South Wales burn patients, comparing 2020 data with the preceding 5 years.

SETTING

Both adult units in the New South Wales Statewide Burn Injury Service (Concord Repatriation General Hospital and Royal North Shore Hospital).

PARTICIPANTS

All adult patients in New South Wales with self-inflicted burn injuries between 1st January 2015 and 31st December 2020.

OUTCOME MEASURES

Demographic information, precipitating factors, burn severity, morbidity and mortality outcomes.

RESULTS

We found18 episodes of self-immolation in 2020, compared to an average of 10 per year previously. Burn size significantly increased (43% total body surface area vs 28%) as did revised Baux score (92 vs 77). Most patients had a pre-existing psychiatric illness. Family conflict and acute psychiatric illness were the most common precipitating factors.

CONCLUSION

2020 saw an increase in both the frequency and severity of self-inflicted burn injuries in New South Wales, with psychiatric illness a major factor.

"So Why Should I Call Them?": Survivor Support Service Characteristics as Drivers of Help-Seeking in India

Women in South Asia face the highest lifetime prevalence of intimate partner violence in the world, which is just one form of violence against women (VAW). In India, few women seek help after experiencing violence, particularly from formal resources, such as physicians or the police. While many studies have investigated the impact of survivor characteristics and patterns of violence on help-seeking behaviors, there is scant research on support service characteristics and their impact on help-seeking. The introduction of a novel crisis helpline in Gujarat, India provided an opportunity to better understand how successful help-seeking can be driven by the perceived and experienced characteristics of the helpline. We conducted in-depth interviews with helpline users to identify factors and pathways that promoted or discouraged help-seeking in general, help-seeking from a formal source, and help-seeking from this particular helpline. We analyzed 32 interviews of women who used the helpline. Participants were from eight districts across the state, representing a diverse range of sociodemographic backgrounds. After conducting a thematic analysis, we found that action-oriented service, timeliness, and women-focused staff influenced (positively and negatively) participants' feelings of safety, empowerment, and trust in the helpline, which ultimately impacted their decision to seek help from the helpline or even to seek help at all. This study illuminates how service characteristics, in and of themselves, can influence the likelihood that survivors will seek help, emphasizing the need for survivors to have a voice in the growth and refinement of VAW support services. Consequently, these areas must be a focus of future research and initiatives to improve help-seeking by VAW survivors.

Assault burn injuries in adolescents and adults in South Africa: risk factors and characteristics

Assault burns comprise a significant subset of burns, with a greater risk of severe injuries. This South African study used a national dataset from major hospitals to identify risks and injury characteristics of assault burns. The analysis sample comprised 2658 adolescent and adult cases and employed logistic regression with bootstrapping to examine the risk of assault compared to unintentional burns. The study indicates that 17.4% of burns were due to assault. Males were 1.5 times more likely than females to be burn assault victims. Compared to adults 55 years and older, young adults 22-39 years were at greatest risk, followed by youth 13-21 years. Assault injuries were five times more likely due to chemical attacks and three times more likely to scalds than to flame burns. The head, neck and trunk were most affected. Where alcohol was indicated, assault burns were five times more likely than unintentional burns. The findings may indicate the need for targeted prevention strategies such as conflict resolution, alcohol use management and the control of corrosive chemicals.

Gender-based disparities in burn injuries, care and outcomes: A World Health Organization (WHO) Global Burn Registry cohort study

BACKGROUND

We aimed to describe the gender-based disparities in burn injury patterns, care received, and mortality across national income levels.

METHODS

In the WHO Global Burn Registry (GBR), we compared patient demographics, injury characteristics, care and outcomes by sex using Chi-square statistics. Logistic regression was used to identify the associations of patient sex with surgical treatment and in-hospital mortality.

RESULTS

Among 6431 burn patients (38 % female; 62 % male), females less frequently received surgical treatment during index hospitalization (49 % vs 56 %, p < 0.001), and more frequently died in-hospital (26 % vs 16 %, p < 0.001) than males. Odds of in in-hospital death was 2.16 (95 % CI: 1.73-2.71) times higher among females compared to males in middle-income countries.

CONCLUSIONS

Across national income levels, there appears to be important gender-based disparities among burn injury epidemiology, treatment received and outcomes that require redress. Multinational registries can be utilized to track and to evaluate initiatives to reduce gender disparities at national, regional and global levels.

Surgical Management Evolution Between 2 Massive Burn Cases at 17-Year Interval: Contribution of Cell Therapies in Improving the Surgical Care

We report the cases of 2 patients admitted to our hospital at a 17-year interval, both with 90% total body surface area (TBSA) burns. These two young patients were in good health before their accident, but major differences in time of intensive care and hospitalization were observed: 162 versus 76 days in intensive care unit and 18 versus 9.5 months for hospitalization, respectively. We have analyzed the different parameters side-by-side during their medical care and we have identified that the overall improved outcomes are mainly due to a better adapted fluid reanimation in combination with the evolution of the surgical management to encompass allogenic cellular therapy (Biological Bandages). Indeed, autologous cell therapy using keratinocytes has been used for over 30 years in our hospital with the same technical specifications; however, we have integrated the Biological Bandages and routinely used them for burn patients to replace cadaver skin since the past 15 years. Thus, patient 1 versus patient 2 had, respectively, 83% versus 80% TBSA for autologous cells, and 0% versus 189% for allogenic cells. Notably, it was possible that patient 2 was able to recover ∼6% TBSA with the use of Biological Bandages, by stimulating intermediate burn zones toward a spontaneous healing without requiring further skin grafting (on abdomen and thighs). The body zones where Biological Bandages were not applied, such as the buttocks, progressed to deeper-stage burns. Despite inherent differences to patients at their admission and the complexity of severe burn care, the results of these two case reports suggest that integration of innovative allogenic cell therapies in the surgical care of burn patients could have major implications in the final outcome.

Poly(lactide-co-ε-caprolactone) scaffold promotes equivalent tissue integration and supports skin grafts compared to a predicate collagen scaffold

Dermal scarring from motor vehicle accidents, severe burns, military blasts, etc. is a major problem affecting over 80 million people worldwide annually, many of whom suffer from debilitating hypertrophic scar contractures. These stiff, shrunken scars limit mobility, impact quality of life, and cost millions of dollars each year in surgical treatment and physical therapy. Current tissue engineered scaffolds have mechanical properties akin to unwounded skin, but these collagen-based scaffolds rapidly degrade over 2 months, premature to dampen contracture occurring 6-12 months after injury. This study demonstrates a tissue engineered scaffold can be manufactured from a slow-degrading viscoelastic copolymer, poly(ι-lactide-co-ε-caprolactone), with physical and mechanical characteristics to promote tissue ingrowth and support skin-grafts. Copolymers were synthesized via ring-opening polymerization. Solvent casting/particulate leaching was used to manufacture 3D porous scaffolds by mixing copolymers with particles in an organic solvent followed by casting into molds and subsequent particle leaching with water. Scaffolds characterized through SEM, micro-CT, and tensile testing confirmed the required thickness, pore size, porosity, modulus, and strength for promoting skin-graft bioincorporation and dampening fibrosis in vivo. Scaffolds were Oxygen Plasma Treatment and collagen coated to encourage cellular proliferation. Porosity ranging from 70% to 90% was investigated in a subcutaneous murine model and found to have no clinical effect on tissue ingrowth. A swine full-thickness skin wound model confirmed through histology and Computer Planimetry that scaffolds promote skin-graft survival, with or without collagen coating, with equal safety and efficacy as a commercially available tissue engineered scaffold. This study validates a scalable method to create poly(ι-lactide-co-ε-caprolactone) scaffolds with appropriate characteristics and confirms in mouse and swine wound models that the scaffolds are safe and effective at supporting skin-grafts. The results of this study have brought us closer towards developing an alternative technology that supports skin grafts with the potential to investigate long-term hypertrophic scar contractures.

Referral Patterns of Burn Injury in Rural Kenya

Burn injury represents a substantial burden of disease in resource-limited settings. Kenya has no formal trauma system and referral practices for burn injuries are not well understood. The purpose of this study was to determine the factors associated with burn injury referrals in rural Kenya. A retrospective chart review was conducted for patients with burn injury from January 1, 2014 to December 31, 2017 at a 300-bed faith-based, teaching hospital in southwest Kenya. Bivariate analysis compared referred and non-referred patients. Multivariable logistic regression was used to assess the association between burn severity and odds of referral adjusting for age, sex, insurance, time from injury to arrival, and estimated travel time from home to hospital. The study included 171 patients with burn injury; 11 patients were excluded due to missing referral data. Of the 160 patients, 31.9% (n = 51) were referred. Referral patients had higher average total body surface area burn (23.1 ± 2.4% vs 11.1 ± 1.2%, P < .001), were more likely to have full-thickness burns (41.3% vs 25.5%, P = .05), and less likely to present to the referral hospital within 24 hours after injury (47.8% vs 73.0%, P = .005). Referral patients had longer travel time to hospital (90+ min: 52.9% vs 22.0%, P < .001). Odds of referral increased 1.62 times (95% confidence interval: 1.19-2.22) for every 10% increase in total body surface area burn. Without a coordinated trauma system, referrals represent a substantial portion of burn injury patients at a hospital in rural Kenya. Referred patients present with more severe burns and experience delays to presentation.

Comparison Among Bone Marrow and Wheat Flour's Mixture and Standard Treatment on Healing Second-Degree Burn Wound in Rats

The treatment of extensive skin burns remains as a challenge for health care personnel. This study aimed to compare the combination of bone marrow and wheat flour with standard treatment on animal models. In this experimental study, 45 male rats were randomly assigned into three groups as follows: The first group was control (no treatment), the second group received bone marrow and wheat flour combination topically, and the third group received standard treatment (1% silver sulfadiazine). The treatment lasted for up to 21 days. On the 22nd day, the rats were killed. The number of blood vessels and hair follicles was measured in the burn wound bed. The area and depth of the wound were also measured. Data were analyzed using SPSS software version 16. The results showed that, complete closure of the wound was better in the bone marrow treated group compared with the group receiving the silver sulfadiazine and the control group. Furthermore, the wound healing was better in the silver sulfadiazine group compared with the control group. Microscopic examination revealed a significant increase in the number of hair follicles and blood vessels in the bone marrow and silver groups compared with the control group. The results showed that, the group treated with bone marrow, because of the presence of mesenchymal and stem cells can cause stimulating angiogenesis and producing vegetative tissue, hence it improved maturation, shrinkage, and contraction of the wound in comparison with the silver sulfadiazine and control groups.

Pattern of homicidal burns in Northern Tunisia: An autopsy-based study over 15 years (2005-2019)

Data about homicidal burns remain scarce. Intentional burns are a challenging situation in the case of an individual found dead in a fire zone with no witness of the fatal act. This study aimed to analyze the victim profiles of homicidal burns in Northern Tunisia. It was a descriptive cross-sectional study with a retrospective data collection over 15 years (January 2005-December 2019). In total, 60 cases of homicidal burns were collected. The mean age was 40.22 ± 18.1 years (range 4-82 years). We noted a male predominance (sex ratio M/F = 1.3). Most of the victims were married (48.3%), unemployed (40%), and living in an urban area (63.3%). Homicidal burns occurred most frequently in private homes for female victims (80.8%) and in public places for male victims (31.4%) (p < 0.001). The reported motive varied according to the victim's sex; males were mostly assaulted by an acquaintance in an interpersonal conflict (47.1%), and females were mostly assaulted by an intimate partner while in a dispute (42.3%; p = 0.001). The median total body surface area (TBSA) that was burned was 60.4%, and burn injuries were observed mainly in the anterior part of the body. In 19 cases, the burns were associated with another type of trauma, from which the most common association was burning and stab wounds (12 cases). The identified pattern of homicidal burn casualties was similar to the reported data in Western countries and to homicides in general in Tunisia, suggesting that prevention measures should address those of intentional interpersonal violence.

New Progress of Adipose-derived Stem Cells in the Therapy of Hypertrophic Scars

Burns are a global public health issue of great concern. The formation of scars after burns and physical dysfunction of patients remain major challenges in the treatment of scars. Regenerative medicine based on cell therapy has become a hot topic in this century. Adipose-derived stem cells (ADSCs) play an important role in cellular therapy and have become a promising source of regenerative medicine and wound repair transplantation. However, the anti-scarring mechanism of ADSCs is still unclear yet. With the widespread application of ADSCs in medical, we firmly believe that it will bring great benefits to patients with hypertrophic scars.

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.

An Analysis of Factors Associated with Burn Injury Outcomes in Low- and Middle-Income Countries

BACKGROUND

Burn injuries are a major cause of morbidity and mortality within low- and middle-income countries (LMICs). The World Health Organization developed the Global Burn Registry to centralize data collection for the guidance of burn prevention programs. This study analyzed the epidemiologic and hospital-specific factors associated with burn injury outcomes in LMICs and high-income countries (HICs).

METHODS

A retrospective review was performed using the Global Burn Registry over 3 y. Patients were stratified by income region. Bivariate analyses and stepwise regressions were performed to evaluate patient and hospital demographics and variables associated with injury patterns and outcomes. Outcomes of interest included mortality and length of stay.

RESULTS

Over the study period, data were collected on 1995 patients from 10 LMICs (20 hospitals) and four HICs (four hospitals). Significantly higher mortality was seen in LMICs compared with HICs (17% versus 9%; P < 0.001). There was no significant difference between income regions for injury patterns (P = 0.062) or total body surface area of the burn injury (P = 0.077). Of the LMIC hospitals in this data set, 11% did not have reliable access to an operating theater.

CONCLUSIONS

HICs had a lower overall mortality even with higher rates of concurrent injuries, as well as longer length of stay. LMIC hospitals had fewer resources available, which could explain increased mortality, given similar total body surface area. This study highlights how investing in health care infrastructure could lead to improved outcomes for patients in low-resource settings.

The effect of foot reflexology massage on burn-specific pain anxiety and sleep quality and quantity of patients hospitalized in the burn intensive care unit (ICU)

BACKGROUND

Burn-specific pain anxiety and sleep disorders are common factors in burned patients that affect wound healing process, as well as the severity of burn pain. This study aimed to investigate the effect of foot reflexology massage on burn-specific pain anxiety and sleep condition of patients hospitalized in the burn ICU.

METHOD

In this randomized controlled clinical trial, 52 patients were assigned by permuted block randomization 1:1 to the intervention (n=26) and control (n=26) groups. The intervention group received 20min of foot reflexology massage during 3 days on their third, fourth and fifth days of hospitalization and 15min before changing wound dressings. Patients in the control group merely received routine care. The Burn-Specific Pain Anxiety Scale (BSPAS) was completed for three consecutive days before and after changing wound dressings, and St. Mary's Hospital Sleep Questionnaire (SMHSQ) was filled out for four consecutive days before changing wound dressings for patients in both groups. The data were analyzed by IBM SPSS 16 software, Chicago, independent t, Chi-square, Friedman, Mann-Whitney and Wilcoxon tests.

FINDINGS

We found no significant difference between pain-anxiety in the two groups before the intervention. The trend of different days in each groups were compared with Friedman test and showed that pain anxiety (p<0.001), sleep latency (p<0.001), duration of the last day's sleep (p<0.001) and satisfaction of the last night sleep (p<0.001) had a significant difference. In addition, Mann-Whitney test results showed that there were significant differences between the two groups at different times in terms of the above variables (p<0.05). The effect size was=0.82 for pain anxiety between group after the intervention.

CONCLUSION

Based on the results, foot reflexology massage can effectively reduce pain anxiety levels and improve sleep quality and quantity of patients with burn injuries; therefore, this non- pharmacological therapeutic method is recommended to be used in the burn ICUs. (Clinical trial's registration code: IRCT20110906007494N27).

Asymmetric Membranes: A Potential Scaffold for Wound Healing Applications

Currently, due to uprising concerns about wound infections, healing agents have been regarded as one of the major solutions in the treatment of different skin lesions. The usage of temporary barriers can be an effective way to protect wounds or ulcers from dangerous agents and, using these carriers can not only improve the healing process but also they can minimize the scarring and the pain suffered by the human. To cope with this demand, researchers struggled to develop wound dressing agents that could mimic the structural and properties of native skin with the capability to inhibit bacterial growth. Hence, asymmetric membranes that can impair bacterial penetration and avoid exudate accumulation as well as wound dehydration have been introduced. In general, synthetic implants and tissue grafts are expensive, hard to handle (due to their fragile nature and poor mechanical properties) and their production process is very time consuming, while the asymmetric membranes are affordable and their production process is easier than previous epidermal substitutes. Motivated by this, here we will cover different topics, first, the comprehensive research developments of asymmetric membranes are reviewed and second, general properties and different preparation methods of asymmetric membranes are summarized. In the two last parts, the role of chitosan based-asymmetric membranes and electrospun asymmetric membranes in hastening the healing process are mentioned respectively. The aforementioned membranes are inexpensive and possess high antibacterial and satisfactory mechanical properties. It is concluded that, despite the promising current investigations, much effort is still required to be done in asymmetric membranes.

Chitosan and phospholipid assisted topical fusidic acid drug delivery in burn wound: Strategies to conquer pharmaceutical and clinical challenges, opportunities and future panorama

Burn is the immense public health issue globally. Low and middle income countries face extensive deaths owing to burn injuries. Availability of conventional therapies for burns has always been painful for patients as well as expensive for our health system. Pharmaceutical experts are still searching reliable, cheap, safe and effective treatment options for burn injuries. Fusidic acid is an antibiotic of choice for the management of burns. However, fusidic acid is encountering several pharmaceutical and clinical challenges like poor skin permeability and growing drug resistance against burn wound microbes like Methicillin resistant Staphylococcus aureus (MRSA). Therefore, an effort has been made to present a concise review about molecular pathway followed by fusidic acid in the treatment of burn wound infection in addition to associated pros and cons. Furthermore, we have also summarized chitosan and phospholipid based topical dermal delivery systems customized by our team for the delivery of fusidic acid in burn wound infections on case-to-case basis. However, every coin has two sides. We recommend the integration of in-silico docking techniques with natural biomacromolecules while designing stable, patient friendly and cost effective topical drug delivery systems of fusidic acid for the management of burn wound infection as future opportunities.

Infrared Thermal Imaging as a Method of Improving Skin Graft Qualification Procedure and Skin Graft Survivability

BACKGROUND

Appropriate wound classification (evaluation of skin damage depth) is a key element in the first days after the burn injury. In this study, we used a thermovision system to evaluate the degree of burn wound shortly after injury and the regenerative process of engraftment of autologous split-thickness skin grafts (STSGs). The results were referenced to wound assessment made by a physician.

METHODS

Twenty-one patients with STSGs were included in the study. The analysis of the dependence between the assessment of burn depth obtained with the use of numeric models (thermovision examination) and clinical assessment by physicians was conducted. Computed tomography angiography (CTA) was performed.

RESULTS

The study demonstrated that thermovision images allowed physicians a deeper assessment of burns. Decrease in the temperature difference was observed in subsequent measurements. Temperature increase during normal graft healing was observed. Graft vascularization was confirmed by CTA.

CONCLUSION

Thermovision may be useful in assessment of the clinical condition of burn wounds and monitoring of wound healing progress.

Deliberate corrosive substance attacks – A systematic review

Introduction

Deliberate corrosive substance attacks (DCSA) have traditionally been associated with low- and middle-income countries (LMIC). However, the incidence of DCSA in certain geographical locations of the UK has increased in recent years. These attacks have a relatively low mortality rate but cause extensive life-changing injuries and the management from point of wounding to definitive care is challenging for all involved.

Methods

A systematic review was used to identify literature about DCSA and establish how much evidence about these attacks has been published over the last decade. Victim and perpetrator characteristics, substances used, injury patterns, mortality, pre-hospital and hospital-based management and complications associated with management were areas of interest. The review included any medical literature (case reports, letters, reviews) published within the last 10 years that described DCSA against human victims. Non-English language articles were excluded.

Results

Eighteen articles containing 762 victims of DCSA were included; seven victims had incomplete data. Articles were mostly from LMIC (Bangladesh, Columbia, Cambodia, India, Iran, Sri Lanka and Pakistan) but there were five articles were from the UK (three ‘Letters to Editors’, one survivor letter and one retrospective review of 21 victims). UK victim and perpetrator characteristics varied from those in LMIC. Seven papers described pre-hospital management and nine described hospital/surgical management.

Conclusions

The evidence base surrounding DCSA is limited especially in the UK setting. More research into the epidemiology and management of DCSA in the UK is warranted.

Survey on Knowledge of First Aid Management of Burns Amongst Medical and Non-medical Students in Karachi, Pakistan: Need for an Educational Intervention?

Background: Burn related injuries (BRIs) are relatively common, mostly accidental, and highly preventable forms of injury. First aid management of BRIs can have a significant impact on the outcome and morbidity of these injuries, yet there seems to be an inadequacy in the knowledge related to burn management worldwide. Hence, our study aimed to delineate the level of knowledge and awareness of burn first aid treatment (BFAT) amongst undergraduate students, and the impact training courses had on that knowledge.

Methods: A cross-sectional study was conducted by employing undergraduate medical and non-medical students from various universities of Karachi, Pakistan. By means of convenience sampling, 400 students were sent online, structured questionnaires. The analysis was conducted using Statistical Package for Social Sciences (SPSS version 23.0, IBM Corp., Armonk, NY, US), and associations calculated through t-tests. A mean knowledge score was calculated to assess the participant’s adequacy of knowledge regarding BFAT.

Results: Medical students had a better knowledge score than their non-medical counterparts (5.8 ± 1.6 versus 3.6 ± 1.5, P < 0.01), however, overall knowledge of BFAT remained inadequate amongst participants. Students who received formal training scored a higher mean knowledge score than the majority of students with no training (P < 0.01).

Conclusion: The majority of students had insufficient overall knowledge about BFAT, highlighting the need for integrating this topic into the curriculum. In addition, education of the masses via multimedia and conducting formal training courses, are both imperative in raising awareness and reducing the occurrence of BRIs.

Spinal cord motor neuron plasticity accompanies second-degree burn injury and chronic pain

Burn injuries and associated complications present a major public health challenge. Many burn patients develop clinically intractable complications, including pain and other sensory disorders. Recent evidence has shown that dendritic spine neuropathology in spinal cord sensory and motor neurons accompanies central nervous system (CNS) or peripheral nervous system (PNS) trauma and disease. However, no research has investigated similar dendritic spine neuropathologies following a cutaneous thermal burn injury. In this retrospective investigation, we analyzed dendritic spine morphology and localization in alpha-motor neurons innervating a burn-injured area of the body (hind paw). To identify a molecular regulator of these dendritic spine changes, we further profiled motor neuron dendritic spines in adult mice treated with romidepsin, a clinically approved Pak1-inhibitor, or vehicle control at two postburn time points: Day 6 immediately after treatment, or Day 10 following drug withdrawal. In control treated mice, we observed an overall increase in dendritic spine density, including structurally mature spines with mushroom-shaped morphology. Pak1-inhibitor treatment reduced injury-induced changes to similar levels observed in animals without burn injury. The effectiveness of the Pak1-inhibitor was durable, since normalized dendritic spine profiles remained as long as 4 days despite drug withdrawal. This study is the first report of evidence demonstrating that a second-degree burn injury significantly affects motor neuron structure within the spinal cord. Furthermore, our results support the opportunity to study dendritic spine dysgenesis as a novel avenue to clarify the complexities of neurological disease following traumatic injury.

Comparison of the characteristics of hot tap water scalds and other scalds in Germany

BACKGROUND/AIM

Mortality associated with hot tap water scalds remains significant, owing to a lack of up-to-date regulations on tap water temperature. We aimed to evaluate the effect of hot tap water scalds on patients admitted to our adult burn intensive care unit (BICU), and compare them to those with other scald types.

METHODS

We enrolled patients treated for scalds at the BICU of Cologne-Merheim Medical Center from 1989 to 2014, and retrospectively analyzed their age, sex-specific differences, characteristics, length of hospital stay, number of operations, and mortality. Patients were categorized into two groups: patients with hot tap water scalds and those with all other types of scalds.

RESULTS

A total of 333 patients were enrolled. In 23.4% (n=78) of the cases, the scalds were associated with hot tap water. Such injuries were more commonly observed in older men than women. Hot tap water scalds involved a significantly higher total burned surface area (TBSA) than other scalds, with TBSA values of 24.0% and 15.9% for men, and 21.8% and 10.9% for women, respectively. Hot tap water scald patients had a greater number of surgeries and longer BICU stays (27.8 days vs 9.1 days), and significantly higher mortality values (30.8% (n=24) vs 4.7% (n=12)) than those with the other scald types.

CONCLUSIONS

Hot water scalds are associated with large TBSAs, long stays in the BICU, and worse outcomes compared to the other scald types.