Geographical analysis of socioeconomic factors in risk of domestic burn injury in London 2007–2013

Understanding burn injury among Aboriginal and Torres Strait Islander children - results of a two-year cohort study

BACKGROUND

Despite known inequalities, little is understood about the burden and healthcare experiences of Aboriginal and Torres Strait Islander children who sustain a burn injury and their families.

METHODS

The Coolamon Study recruited parents and carers whose children (aged <16 years) were Aboriginal and / or Torres Strait Islander children and had presented to burn units across four Australian states, New South Wales (Sydney), Northern Territory (Darwin), Queensland (Brisbane, Townsville) and South Australia (Adelaide), between 2015 and 2018. Consent was obtained and carers completed baseline and subsequent interviews at 3, 6, 12 and 24 months. Data were collected on the injury event, patient care and safety, sociodemographic factors, health related quality of life (PedsQual), and psychological distress (Kessler K-5).

RESULTS

Of the 208 participants, 64 % were male; 26 % were aged less than 2 years and 37 % aged 2-4 years. The most common burn mechanisms were scalds (37 %), contact (33 %) and flame burns (21 %), with more severe burns and flame burns occurring in rural and remote settings. Most carers rated their child's care as either excellent or very good (82 %). Family distress, measured by the K-5, lessened over the 24 months, however the changes were not statistically significant. While 77 % of carers reported that they received enough information, 18 % reported they would have liked more, and 3 % reported no information was provided before treatment. Parents described mixed access to information about the types of support available to them, such as accommodation, meals, travel or cultural support.

CONCLUSION

Data from this cohort provide rich new information about risk factors and care received from point of injury through to rehabilitation for Aboriginal and Torres Strait Islander children with burns, providing unique insights into what is needed for appropriate, culturally safe care.

Burns among adults in a major Malawian burn unit: epidemiology and factors associated with prolonged hospital stay

Aim

This study sought to describe the epidemiology of burns and factors associated with prolonged hospital stay among adult patients admitted in the Queen Elizabeth Central Hospital burns unit.

Methods

All files of patients aged at least 17 years and admitted in the Queen Elizabeth Central Hospital burns unit between 1 June 2007 and 31 May 2017 with acute burns, were reviewed. Data on socio-demographic characteristics, injuries sustained, comorbidities, length of hospital stay, and clinical outcomes were extracted from the files. Summary statistics, independent sample T-test, and odds ratios were computed to determine the distribution and associations of the variables collected.

Results

A total of 515 patient files, all from rural or informal urban settlements, were reviewed. The median age at the time of presentation was 32 years (IQR: 25-45), and 52% (n=279) were male. Most of the burns occurred at home (81.0%; n=379), were of flame etiology (75.7%; n=385), and were reported to have been accidental (94.7%, n=445). The mean monthly rate of new burn injury patients was highest in the cool-dry season, and epileptic seizures were a common precedent of burn injury (30.7%; n=158). Most (62.7%) of the patients with recorded burn sites sustained multiple burns injuries, and more than half of the patients had upper and lower limb burns (64.6% & 59.5% respectively). Thirty patients sustained additional non-burn injuries, and 26.4% (n=132) of all patients with recorded outcomes died in the hospital.

Conclusion

The data on burn injuries among adults presenting at the QECH burns unit suggests the existence of socio-economic inequalities associated with burn incidence. There is also a need for improvement in the quality and uptake of epilepsy care in primary care facilities.

Keeping our children safe: piloting a hospital-based home-visitation program in Israel

Background

Unintentional childhood injuries are a leading cause of morbidity and mortality worldwide. Attempts to prevent child home injuries have rarely been implemented in hospital settings which present an important opportunity for intervention. The SHABI (‘Keeping our Children Safe; SHomrim Al BetIchut Yeladenu’) program recruits at-risk families presenting with child injury to the Emergency Department. Medical/nursing students conduct two home visits and provide safety equipment and guidance. The objective of this study was to investigate the impact of SHABI on participating families’ home-safety.

Methods

The pilot was conducted between May 2019 and March 2020 in northern Israel, an area with high child injury rates. Eligibility included families with preschool children who incurred a home injury. Home-safety was assessed by observation through the ‘Beterem’ checklist. Parents' views, knowledge, awareness of dangers and report of home injuries were assessed at the start of each visit.

Results

352 of 773 eligible families agreed to be contacted. 135 participated, 98 completed both home visits. Significant improvement in home-safety items was observed 4 months after the first visit (14 [IQR12-16]) vs. (17 [IQR15-19]; p < 0.001), accompanied by an overall increase in home safety (Mean ± SD 71.9% ± 9.5% vs. 87.1% ± 8.6%; p < 0.001). 64% reported greater awareness of dangers, 60% affirmed home was safer, and 70% valued the equipment. No difference was found in the prevalence of injuries (14 of 98 families prior and 8 after the visit; p = 0.17). Home visitors reported benefiting from the experience of working with disadvantaged families.

Conclusion

The program, which included recruitment in a hospital emergency setting and use of healthcare students as home visitors, was successfully implemented and accompanied by significant improvement in home safety with a non-significant trend of child injury decrease.

Sociodemographic Patterns of Pediatric Patients in Specialized Burn Care in Sweden

Trauma is a leading cause of mortality in children. Burns affect children disproportionally. Although burn incidence and mortality are decreasing, differences in the risk depend on socioeconomic status. The present study aimed to investigate the sociodemographic patterns of pediatric patients (0-17 years) managed at the two burn centers in Sweden, Uppsala, and Linköping, between 2010 and 2020.

METHOD

This retrospective register-based study used hospital records from the two burn centers combined with information from Statistics Sweden plus data regarding number of asylum seekers from the Swedish Migrations Agency. Choropleth maps representing the patients' geographical distribution were created. Information about income levels per geographic area was added. A Wilcoxon signed-rank test was performed to investigate differences in median income levels between the areas where the patients lived, related to Sweden's median income.

RESULTS

The study included 2455 patients. Most of the children aged below 5 years (76%) and were boys (60%). The mean percentage of total skin area was 4.2%. There was no significant increment or decrease in the incidence of pediatric burns during the study. Most patients with recorded zip codes lived in areas with an income level below the national median (n = 1974, 83%). Children with asylum status were over-represented compared with residents and/or Swedish citizens.

CONCLUSIONS

In Sweden, most pediatric burns occur in families that live in areas with low-income levels. Pediatric burns affect children with asylum status disproportionally compared with those who are residents in and/or citizens of Sweden. Prevention strategies should be designed and implemented to alleviate this health inequity.

Does Socioeconomic Status or Methamphetamine use Impact Discharge Opioid Requirements in Burn Injured Patients?

Methamphetamine (MA) use is associated with lower socioeconomic status (SES) and increased opioid use. Though MA use itself has been linked to larger burn injuries and increased length of stay, studies examining the effect of SES on opioid use in this patient population remain limited. The aim of this work was to examine how both SES and/or MA use in burn patients impacted discharge opioid requirements. Records of burn patients admitted to an ABA verified burn center were reviewed from January 2016 to December 2017. Patients were grouped into MA positive (MPOS) or negative groups (MNEG) based on admission urine toxicology screening. Pain scores, oral morphine opioid equivalents (OE), and adjunct pain medication use reported within 24 hours of discharge were examined. SES was determined by zip code. No difference was found between MPOS and MNEG groups regarding discharge OE (p=0.4), OE/TBSA (p=0.79), or pain score (p=0.09). Low SES was more prevalent in MPOS patients (p&lt;0.0001) but low SES was not a predictor of discharge OE (p=0.7), OE/TBSA (p=0.7), or pain score (p = 0.15). Discharge OE and OE/TBSA requirements correlated with discharge pain score (p&lt;0.0001) and LOS (p&lt;0.01), but not SES. Multivariate linear regression found that MNEG status (p=0.005), pain score (p &lt; 0.0001), concurrent use of benzodiazepines and gabapentin (p&lt;0.001), but not low SES, were independently associated with increased OE. Although lower SES was seen in patients using MA, SES was not associated with discharge opioid use or pain scores. Additional work will be necessary to determine factors affecting opioid use in this population.

Spatiotemporal mapping of major trauma in Victoria, Australia

BACKGROUND

Spatiotemporal modelling techniques allow one to predict injury across time and space. However, such methods have been underutilised in injury studies. This study demonstrates the use of statistical spatiotemporal modelling in identifying areas of significantly high injury risk, and areas witnessing significantly increasing risk over time.

METHODS

We performed a retrospective review of hospitalised major trauma patients from the Victorian State Trauma Registry, Australia, between 2007 and 2019. Geographical locations of injury events were mapped to the 79 local government areas (LGAs) in the state. We employed Bayesian spatiotemporal models to quantify spatial and temporal patterns, and analysed the results across a range of geographical remoteness and socioeconomic levels.

RESULTS

There were 31,317 major trauma patients included. For major trauma overall, we observed substantial spatial variation in injury incidence and a significant 2.1% increase in injury incidence per year. Area-specific risk of injury by motor vehicle collision was higher in regional areas relative to metropolitan areas, while risk of injury by low fall was higher in metropolitan areas. Significant temporal increases were observed in injury by low fall, and the greatest increases were observed in the most disadvantaged LGAs.

CONCLUSIONS

These findings can be used to inform injury prevention initiatives, which could be designed to target areas with relatively high injury risk and with significantly increasing injury risk over time. Our finding that the greatest year-on-year increases in injury incidence were observed in the most disadvantaged areas highlights the need for a greater emphasis on reducing inequities in injury.

Pediatric burns unique characteristics among Ultra-Orthodox Jewish minority - retrospective study

BACKGROUND AND OBJECTIVES

Burn injuries are a significant cause of morbidity among children. Ultra-Orthodox Jewish children are at higher risk for burn injuries. The goal of this study was to examine the clinical characteristics of moderate to severe burns in this population in comparison to the general population in Israel.

METHODS

This retrospective cohort study included all pediatric patients 0-18 years of age admitted with burn injuries from January 1, 2015 through December 31, 2018. Data was collected regarding demography, etiology and clinical characteristics.

RESULTS

Of 778 burns injuries presented to our tertiary center, 385 (49.5%) were hospitalized. Of those 212 (55%) were non-Ultra-Orthodox Jews, 135 (35%) were Ultra-Orthodox Jews, and 38 (10%) were non-Jewish patients. The Total Body Surface Area percentage (TBSA%) of scald-type burns was larger in Ultra-Orthodox compared to non-Ultra-Orthodox children (median TBSA% of 7% Vs 5% respectively(p<0.05)). Among the Ultra-Orthodox group, the median TBSA percentage during weekdays was 6%, and for weekends the TBSA% was 7.5% (p<0.05). Females demonstrated the greatest diversity between subgroups. On weekends, Ultra-Orthodox female's median TBSA% was 10%, and non-Ultra-Orthodox female's TBSA% was 4.5% (p<0.05).

CONCLUSIONS

Ultra-Orthodox children and especially girls had a significantly higher median TBSA% than non-Ultra-Orthodox children for burns occurring during weekends. This may be the result of the unique cultural norms of the Ultra-Orthodox Jewish community, in particular, their lifestyle and observation of the Sabbath. These findings provide focus for better intervention and prevention of pediatric burns among this unique population.

Potential for Machine Learning in Burn Care

INTRODUCTION

Burn-related injuries are a leading cause of morbidity across the globe. Accurate assessment and treatment have been demonstrated to reduce the morbidity and mortality. This essay explores the forms of artificial intelligence to be implemented the field of burns management to optimise the care we deliver in the National Health Service (NHS) in the UK.

METHODS

Machine Learning methods which predict or classify are explored. This includes linear and logistic regression, artificial neural networks, deep learning, and decision tree analysis.

DISCUSSION

Utilizing Machine Learning in burns care holds potential from prevention, burns assessment, predicting mortality and critical care monitoring to healing time. Establishing a regional or national Machine Learning group would be the first step towards the development of these essential technologies.

CONCLUSION

The implementation of machine learning technologies will require buy-in from the NHS health boards, with significant implications with cost of investment, implementation, employment of machine learning teams and provision of training to medical professionals.

Neighborhood risk: Socioeconomic status and hospital admission for pediatric burn patients

BACKGROUND

Burn injury continues to cause significant morbidity and mortality in the US pediatric population. Many studies using inpatient samples have found a relationship between low socioeconomic status (SES) and burn injury. The purpose of our study was to evaluate the association between SES and the likelihood of admission for Emergency Department (ED) visits for pediatric burn injury.

STUDY DESIGN

A retrospective database review of pediatric ED visits for burn injury from a statewide hospital system, from January 1, 2005 to December 31, 2014. SES was assigned using an eight factor Neighborhood Risk Index (NRI) created from census block group data, with a higher score indicative of lower SES. The outcome measure was ED visits admitted to inpatient care.

RESULTS

We analyzed a sample of 1845 pediatric ED visits for burn injuries. Most visits were discharged from the ED (88.4%) while 10.5% were admitted to inpatient care and 1.0% were transferred to another hospital. In a multivariable logistic regression model, patients from high risk areas (>75th percentile NRI) had 1.58 higher odds of inpatient admission compared to patients from low risk areas (<75th percentile NRI; 95% CI: 1.08-2.30), after adjusting for age, gender, ethnicity, distance to the hospital, and previous ED visit for burn injury in the past 30 days. In addition, for every 1-mile increase in distance, a child's likelihood of admission increased by 6% (95% CI: 4-9%).

CONCLUSIONS

Children with a burn injury from the highest risk socioeconomic areas in Rhode Island had a higher likelihood of inpatient admission. Further research is needed to determine what factors associated with socioeconomic status impact this finding.

Social Complexity and Risk for Pediatric Burn Injury: A Systematic Review

Social complexity in health outcomes has been attributed to greater risk of injury, adverse health consequences, and early death in a variety of populations. To determine what social complexity factors associated with burn injury in children, a systematic review of the literature was performed. Two different databases (PubMed and SCOPUS) were searched for articles related to environmental and social determinants of burn injury. Selected literature examined social complexity factors to establish the strength of evidence in relation to incidence of burn injury in children. The extent of factors and the most common social complexities were reviewed. The 641 manuscripts found in PubMed and 327 from SCOPUS were initially reviewed for duplication and English language. Subsequently, manuscripts were selected for relevance based on titles followed by abstracts. Forty-seven manuscripts were reviewed in their entirety. The literature supports a relationship between an increased incidence of pediatric burns in lower income families, children with behavioral disorders, fewer years of parental education and children residing in a rural setting. The majority of reports came from Europe followed by Australia, and scattered information from other countries. Social complexity factors in the environment of the child are associated with an increased risk of burn injury in children. The literature supports the influence of lower income, lower parental education, behavioral disorders and living rurally with an increased incidence of injury. By identifying children at increased risk, it is possible to develop targeted burn prevention and education programs to mitigate burn injury.

Development and implementation of a COVID-19 near real-time traffic light system in an acute hospital setting

Common causes of death in COVID-19 due to SARS-CoV-2 include thromboembolic disease, cytokine storm and adult respiratory distress syndrome (ARDS). Our aim was to develop a system for early detection of disease pattern in the emergency department (ED) that would enhance opportunities for personalised accelerated care to prevent disease progression. A single Trust's COVID-19 response control command was established, and a reporting team with bioinformaticians was deployed to develop a real-time traffic light system to support clinical and operational teams. An attempt was made to identify predictive elements for thromboembolism, cytokine storm and ARDS based on physiological measurements and blood tests, and to communicate to clinicians managing the patient, initially via single consultants. The input variables were age, sex, and first recorded blood pressure, respiratory rate, temperature, heart rate, indices of oxygenation and C-reactive protein. Early admissions were used to refine the predictors used in the traffic lights. Of 923 consecutive patients who tested COVID-19 positive, 592 (64%) flagged at risk for thromboembolism, 241/923 (26%) for cytokine storm and 361/923 (39%) for ARDS. Thromboembolism and cytokine storm flags were met in the ED for 342 (37.1%) patients. Of the 318 (34.5%) patients receiving thromboembolism flags, 49 (5.3% of all patients) were for suspected thromboembolism, 103 (11.1%) were high-risk and 166 (18.0%) were medium-risk. Of the 89 (9.6%) who received a cytokine storm flag from the ED, 18 (2.0% of all patients) were for suspected cytokine storm, 13 (1.4%) were high-risk and 58 (6.3%) were medium-risk. Males were more likely to receive a specific traffic light flag. In conclusion, ED predictors were used to identify high proportions of COVID-19 admissions at risk of clinical deterioration due to severity of disease, enabling accelerated care targeted to those more likely to benefit. Larger prospective studies are encouraged.

Update on hyperbaric oxygen therapy in burn treatment

Hyperbaric oxygen therapy (HBOT) has been shown to improve tissue hypoxia, neovascularization and ischemia reperfusion injury and reduce pathologic inflammation in various clinical settings and was proposed to be a game changer in treatment of burns. Improved and faster wound healing as well as a reduction of morbidity and mortality after thermal and concomitant carbon monoxide poisoning are expected. In defiance of the observed benefits for burn wounds and carbon monoxide poisoning in animal models and few randomized controlled trials there is an ongoing controversy regarding its use, indications and cost effectiveness. Furthermore, the use of HBOT, its indications and the evidence behind its efficiency are still widely unknown to most physicians involved in the treatment of burn patients. Therefore, a review of the up to date evidence-based literature was performed with a focus on available data of HBOT in burn care, to elaborate its use in acute thermal injury and carbon monoxide intoxication. Although beneficial effects of HBOT seem very likely insufficient evidence to support or disprove the routine use of HBOT in the treatment of burn care was found. Although difficult to carry out because of the high interindividual variability of burns and chronic wounds, the need for larger high-quality prospective randomized double-blinded controlled multicenter trials are necessary to be able to evaluate useful applications, expense and cost-efficiency of HBOT for burn care.

Socioeconomic inequalities in injuries treated in primary care in Madrid, Spain

Background

Socioeconomic inequalities in injury morbidity are an important yet understudied issue in Southern Europe. This study analysed the injuries treated in primary care in the Community of Madrid, Spain, by socioeconomic status (SES), sex and age.

Methods

This was a cross-sectional study of injuries registered in the primary care electronic medical records of the Madrid Health Service in 2012. Incidence stratified by sex, SES and type of injury were calculated. Poisson regression was performed.

Results

A statistically significant upward trend in global injury incidence was observed with decreasing SES in all age groups. By type of injury, the largest differences were observed in injuries by foreign body in men aged 15-44 and in poisonings in girls under 15 years of age. Burns risk also stood out in the group of girls under 15 years of age with the lowest SES. In the group above 74 years of age, wounds, bruises and sprains had the lowest SES differences in both sexes, and the risk of fractures was lower in the most socioeconomically advantaged group.

Conclusion

People with lower SES were at a greater risk of injury. The relationship between SES and injury varies by type of injury and age.

Socioeconomic status, gender, and burn injury: A retrospective review

Burn injury rates appear to be influenced by socioeconomic status (SES) and gender globally, but the impact of poverty and gender on burn injury has not been studied in a developed country. This study was a retrospective chart review conducted at a regional burn center in the Southwest US that included 340 patients with TBSA burns >15%. SES was determined using zip code and US census data. The distribution of mechanism of injury was significantly different by gender (χ²(6) = 36.14, p < 0001), but not significantly different by SES (χ²(12) = 19.68, p = 0.073). Burn rates in women was found to have a significant and linear increase (χ² = 13.8513, p = 0.001) with increasing poverty. Women had higher frequencies of being burned at home, and men had higher frequencies of being burned at work. While poverty did not appear to increase the risk of burn injury overall in a mixed population, it was associated with a significant increase in the risk of burn injury in women. Thus, strategies for decreasing risk factors should be targeted toward low SES females and the working male.

An overview of geospatial methods used in unintentional injury epidemiology

Background

Injuries are a leading cause of death and disability around the world. Injury incidence is often associated with socio-economic and physical environmental factors. The application of geospatial methods has been recognised as important to gain greater understanding of the complex nature of injury and the associated diverse range of geographically-diverse risk factors. Therefore, the aim of this paper is to provide an overview of geospatial methods applied in unintentional injury epidemiological studies.

Methods

Nine electronic databases were searched for papers published in 2000–2015, inclusive. Included were papers reporting unintentional injuries using geospatial methods for one or more categories of spatial epidemiological methods (mapping; clustering/cluster detection; and ecological analysis). Results describe the included injury cause categories, types of data and details relating to the applied geospatial methods.

Results

From over 6,000 articles, 67 studies met all inclusion criteria. The major categories of injury data reported with geospatial methods were road traffic (n = 36), falls (n = 11), burns (n = 9), drowning (n = 4), and others (n = 7). Grouped by categories, mapping was the most frequently used method, with 62 (93%) studies applying this approach independently or in conjunction with other geospatial methods. Clustering/cluster detection methods were less common, applied in 27 (40%) studies. Three studies (4%) applied spatial regression methods (one study using a conditional autoregressive model and two studies using geographically weighted regression) to examine the relationship between injury incidence (drowning, road deaths) with aggregated data in relation to explanatory factors (socio-economic and environmental).

Conclusion

The number of studies using geospatial methods to investigate unintentional injuries has increased over recent years. While the majority of studies have focused on road traffic injuries, other injury cause categories, particularly falls and burns, have also demonstrated the application of these methods. Geospatial investigations of injury have largely been limited to mapping of data to visualise spatial structures. Use of more sophisticated approaches will help to understand a broader range of spatial risk factors, which remain under-explored when using traditional epidemiological approaches.

Electronic supplementary material

The online version of this article (doi:10.1186/s40621-016-0097-0) contains supplementary material, which is available to authorized users.