Upper Extremity Burns in the Developing World: A Neglected Epidemic

Epidemiological and clinical characteristics of burns in adults: a 6-year retrospective study in a major burn center in Suzhou, China

Background

Burns are a prevalent form of unintentional injury and a significant public health concern in developing countries. We aimed to investigate the epidemiological and clinical characteristics of adult burn patients at a major center in Eastern China.

Methods

This 6-year retrospective study analyzed patients with varying degrees of burns between January 2017 and December 2022 at the Suzhou Burns and Trauma Center. The study extracted demographic, clinical, and epidemiological data from electronic medical records for analysis.

Results

The study included 3,258 adult patients, of which 64.3% were male. The largest age group affected 30-59-year-old adults (63.04%). Scalds were the leading cause of burns (1,346, 41.31%), followed by flames (1,271, 39.01%). The majority of burn hospitalizations were those with moderate burns (1791, 54.97%). The morbidity rate was low at 0.68%, while mortality was strongly associated with age, etiology, and total body surface area. Patients with certain types of burns, such as explosions, hot crush injuries, and electric burns had more operations, longer lengths of hospital stay, and higher costs compared to those with scalds and flame injuries.

Conclusion

Different prevention strategies should be formulated according to different etiologies, ages, and genders.

Grill-Related Burn Injuries: A Matched Cohort Study

Barbequing can result in devastating burn injuries with unsafe practices. This study aims to characterize the demographics, injury characteristics, and outcomes of grill-related burns and identify ways of burn prevention. A retrospective review of patients admitted to a single-institution, metropolitan burn center from January 1, 2017, to July 1, 2023. Data included demographics, burn injury characteristics, and outcomes. Each Grill Cohort patient was matched to 3 nongrill controls by mBaux score and burn location. Of 2355 patients, 69 (2.9%) met Grill Cohort inclusion criteria. The Grill Cohort had 55 (79.7%) males and an average age of 41.7 ± 17.5 years old. In the Grill Cohort, 25 (36.2%) patients had positive blood alcohol, 8 (11.6%) tested positive for amphetamines, and 5 (7.2%) for cocaine at the time of admission. A total of 61 (88.4%) Grill Cohort burns involved the upper extremity, 43 (62.3%) the head/neck, 34 (49.3%) the lower extremity, and 30 (43.5%) the trunk. Compared with the Control Cohort, the Grill Cohort had smaller proportions of patients who were undomiciled (P < .01) or had a history of mental illness (P < .001). Grill-related burns had a greater proportion of flash/flame burns (P < .001). This study suggests that middle-aged, domiciled males without psychiatric comorbidities are more likely to make preventable grilling errors resulting in burn injuries. Prevention strategies targeting this demographic group should emphasize the risks of grilling while intoxicated, proper handling of propane tanks and lighter fluid, and the use of flash/flame-resistant gear protecting the upper extremities and head/neck.

The Perceived Informational Needs of Family Caregivers of Children Hospitalized in a Burn Department: A Cross-sectional Study

Children are most vulnerable to burn injuries, and their families are their most important source of support. Therefore, it is necessary to identify the information needs of such parents and support them to help children adapt to the new situation, recover to pre-accident conditions, and reintegrate into school and society. This study aimed to investigate the perceived information needs of family caregivers of children admitted to the burn wards of hospitals. This cross-sectional study was conducted on 200 family caregivers of children admitted to the burn ward of a hospital in Tabriz, Iran. Participants were selected through convenience sampling, and the required data were collected by using questionnaires on socio-demographic information, information needs, information resources, and information acquisition methods. The obtained data were analyzed statistically using descriptive statistics (mean, standard deviation, frequency, and percentage) and inferential statistics (Mann-Whitney, Kruskal-Wallis, and Spearman correlation tests). Results indicated that the greatest informational need among family caregivers was related to the child's condition. The treatment team was identified as the most important source of information for them. It was found that information should be provided in a comprehensive and understandable manner, while maintaining honesty and human dignity. The study findings contribute to our understanding of the specific information needs of family caregivers in managing the medical care of children with burns. These findings can serve as a basis for interventions and support services aimed at meeting the needs of these families and improving the quality of care for children with burns.

Medico-legal evaluation of burn trauma injuries. Epidemiological features and predictors of mortality and other adverse outcomes

INTRODUCTION

Burn trauma is a devastating, life-threatening public health issue responsible for significant morbidity and mortality. Developing countries suffer more from the medical, psychological, and economic consequences of burns. The current study aimed to investigate the medicolegal aspects of burn trauma by identifying the epidemiological factors and injury characteristics associated with increased risk of mortality, intentional infliction, and different types of complications.

METHODS

A prospective cross-sectional study was conducted enrolling the burn trauma patients admitted to Burn Unit, Tanta University Hospital, Egypt over one year.

RESULTS

The current study was conducted among 138 burn trauma patients with a case fatality rate of 13.8 %. Of them, 5.8 % were victims of intentional burns, 44.9 % were complicated, and the length of hospital stay ranged between one day and 52 days. Patients aged less than 10 years constituted about 33.3 %. The burn trauma was the highest in June, May and March. Intentionally exposed patients, patients with third-degree burns affecting the head, neck and trunk and those with burns involving a total body surface area (TBSA) of more than 33 % were at high mortality risk. Intentional burns were induced mainly by flame (100 %) and characterized by high severity (TBSA = 85 % and 87.5 % third-degree burns). Intentional burns involved mainly the trunk (p = 0.002) and external genitalia (p = 0.022). The involved TBSA and the highest burn degree were significant predictors of mortality with an excellent area under curves of 0.956 and 0.870, respectively and (p < 0.001). The TBSA of more than 17 % and the burn degrees above the second were significant predictors of in hospital complications (p < 0.001). Daytime intentional burns, burns involving the upper extremities and face, deep and widely distributed burns, and infected wounds were associated with a significant need for surgical treatments. The median length of hospital stay was ten days, primarily attributed to the in hospital complications (p = 0.02).

CONCLUSION

A high degree of vigilance and accurate assessment of burn size, depth and distribution with meticulous interpretation of the mechanism of infliction are central not only for treatment interventions but from the medicolegal point of view.

Massage, laser and shockwave therapy improve pain and scar pruritus after burns: a systematic review

QUESTIONS

In adults with a burn injury, do non-invasive therapies improve pain and burn scar pruritus, elasticity and vascularisation? Are any effects maintained beyond the intervention period?

DESIGN

Systematic review of randomised trials with meta-analyses.

PARTICIPANTS

Adults with burn scars.

INTERVENTION

The experimental intervention was a non-invasive (ie, non-surgical or non-pharmacological) therapy applied to the burn scar.

OUTCOME MEASURES

Pain intensity, pruritus intensity, elasticity and vascularisation.

RESULTS

Fifteen trials involving 780 participants were included. The results indicated a beneficial effect on pain intensity on a 0-to-10 scale after massage (MD -1.5, 95% CI -1.8 to -1.1), shockwave therapy (MD -0.8, 95% CI -1.2 to -0.4) and laser (MD -4.0, 95% CI -6.0 to -2.0). The results indicated a beneficial effect on pruritus intensity on a 0-to-10 scale after massage (MD -0.4, 95% CI -0.7 to -0.2), shockwave therapy (MD -1.3, 95% CI -2.3 to -0.3) and laser (MD -4.8, 95% CI -6.1 to -3.5). Massage, shockwave therapy and silicone produced negligible or unclear benefits on scar elasticity and vascularisation. The quality of evidence varied from low to moderate.

CONCLUSION

Among all commonly used non-invasive therapies for the treatment of burn scars, low-to-moderate quality evidence indicated that massage, laser and shockwave therapy reduce pain and the intensity of scar pruritus. Low-to-moderate quality evidence suggested that massage, shockwave therapy and silicone have negligible or unclear effects for improving scar elasticity and vascularisation.

REVIEW REGISTRATION

PROSPERO (CRD42021258336).

Scars

Wound healing occurs as a response to disruption of the epidermis and dermis. It is an intricate and well-orchestrated response with the goal to restore skin integrity and function. However, in hundreds of millions of patients, skin wound healing results in abnormal scarring, including keloid lesions or hypertrophic scarring. Although the underlying mechanisms of hypertrophic scars and keloid lesions are not well defined, evidence suggests that the changes in the extracellular matrix are perpetuated by ongoing inflammation in susceptible individuals, resulting in a fibrotic phenotype. The lesions then become established, with ongoing deposition of excess disordered collagen. Not only can abnormal scarring be debilitating and painful, it can also cause functional impairment and profound changes in appearance, thereby substantially affecting patients' lives. Despite the vast demand on patient health and the medical society, very little progress has been made in the care of patients with abnormal scarring. To improve the outcome of pathological scarring, standardized and innovative approaches are required.

The effect of mirror therapy on joint movement, pain and functionality in acute upper limb burns

OBJECTIVE

Mirror therapy is aimed at developing a normal proprioceptive perception for the area with pain or movement restriction by making use of the person's monitoring of the healthy side movements thanks to the mirror's reflective feature. The aim of this study is to investigate the effect of mirror therapy on joint range of motion, pain and functionality in acute upper extremity burn injuries.

METHODS

Demographic and burn-specific data of individuals with upper extremity burns were recorded. Individuals were divided into two groups. Standard treatment was applied to the first group, and mirror treatment in addition to the standard treatment was applied to the second group for 30 sessions, 5 days a week for 6 weeks. In the standard treatment program, passive, active-assisted and active ROM, strengthening, stretching, resistant and functional exercises were applied. In the mirror therapy group, active exercises were performed on the healthy side by covering the burn area in the mirror box. Before and after the treatment, joint range of motion(ROM) was evaluated with Universal Goniometer, pain intensity was evaluated with Visual Analog Scale and upper extremity functions were evaluated with QuickDASH.

RESULTS

A total of 32 (23 Male, 9 Female) individuals between the ages of 18-65 were included. The mean total burn surface area was 12.93 ± 9.80 in the standard treatment and 6.12 ± 2.96 in the mirror treatment. The groups were similar in terms of ROM change (p > 0.05). The pretest/posttest pain scores of both the standard therapy and mirror therapy groups were similar (p > 0.05). There was no statistically significant difference in terms of pretest and posttest QuickDASH scores according to the groups (p > 0.05). The difference between the pretest/posttest QuickDASH scores of both Standard treatment and Mirror treatment groups was statistically significant.

CONCLUSION

This study showed that the standard physiotherapy and rehabilitation program applied in the acute period in upper extremity burns and the mirror treatment applied in addition to this program provide similar improvements in joint range of motion and pain.

Management of Severe Extended Burn Axillary Contracture in a Low-resource Setting

Contracture is a common complication of deep burn injury, affecting up to one-third of patients. Although some degree of contracture occurs in any setting, severe extended axillary contractures are more often due to unavailable or inappropriate care. Very few cases have been described in the literature. Their management can be especially challenging in a low-resource environment. The purpose of this article is to present two cases in which severe postburn axillary contractures were effectively managed in a low resource setting, using an island perforator flap coupled with a skin graft or advancement flap. In severe extended axillary contracture, more than one technique is often required to cover the large defect created after contracture release.

Emergency Care for Burn Patients-A Single-Center Report

Burns, one of the main public health problems, lead to significant mortality and morbidity. Epidemiological studies regarding burn patients in Romania are scarce. The aim of this study is to identify the burn etiology, demographics, clinical characteristics, and outcomes in patients requiring treatment in a regional burn unit.

DESIGN

We performed a retrospective observational study of 2021.

PATIENTS

All patients admitted to our six-bed intensive care unit (ICU) were included.

INTERVENTIONS

The following data were collected for further analysis: demographics, burn pattern (etiology, size, depth, affected body region), type of ventilation, ABSI (Abbreviated Burn Severity Index) score, comorbidities, bioumoral parameters, and hospitalization days.

RESULTS

There were 93 burned patients included in our study that were divided into two groups: alive patients' group (63.4%) and deceased patients' group (36.6%). The mean age was 55.80 ± 17.16 (SD). There were 65.6% male patients, and 39.8% of the patients were admitted by transfer from another hospital. Further, 59 patients presented third-degree burns, from which 32.3% died. Burns affecting >37% of the total body surface area (TBSA) were noticed in 30 patients. The most vulnerable regions of the body were the trunk (p = 0.003), the legs (p = 0.004), the neck (p = 0.011), and the arms (p = 0.020). Inhalation injury was found in 60.2% of the patients. The risk of death in a patient with an ABSI score > 9 points was 72 times higher. Comorbidities were present in 44.1% of the patients. We observed a median LOS (length of stay) of 23 days and an ICU-LOS of 11 days. Logistic regression analysis showed that admission protein, creatinkinase, and leukocytes were independent risk factors for mortality. The general mortality rate was 36.6%.

CONCLUSION

A thermal factor was responsible for the vast majority of burns, 94.6% of cases being accidents. Extensive and full-thickness burns, burns affecting the arms, inhalation injuries, the need for mechanical ventilation, and a high ABSI score represent important risk factors for mortality. Considering the results, it appears that prompt correction of protein, creatinkinase, and leukocytes levels may contribute to improvement in severe burn patients' outcomes.

Cytotoxicity, Epidermal Barrier Function and Cytokine Evaluation after Antiseptic Treatment in Bioengineered Autologous Skin Substitute

Bioengineered autologous skin substitutes (BASS) technology is an emerging field for skin burn therapy. However, further studies on BASS characterization, viability against standard procedures for wound healing, and protocol optimization are necessary for the improvement of BASS technology for clinical use. The aim of this study is to evaluate the effect of common antiseptics for clinical use in BASS, focusing on cell viability, inflammatory cytokine pattern, and epithelium and skin barrier integrity, in order to establish the most adequate treatment for wound care after BASS grafting. Human keratinocytes (hKT) and dermal fibroblasts (hDF) were isolated from foreskin samples and integrated into hyaluronic acid-based BASS. The following antiseptics were applied every 48 h: ethanol (70%), chlorhexidine digluconate (1%), sodium hypochlorite (0.02%), povidone iodine (100 mg/mL), and polyhexanide (0.1%), during a follow-up of 16 days. Sodium hypochlorite was the only treatment that showed a high cell viability percentage throughout the evaluation time compared to other antiseptic treatments, as well as a similar cytokine secretion pattern as control BASS. No significant differences were found regarding epidermal barrier function. These findings point towards sodium hypochlorite being the least aggressive antiseptic treatment for BASS post-transplantation wound care.

Inhibition of Bruton's Tyrosine Kinase Protects Against Burn Sepsis-Induced Intestinal Injury

This study aimed to investigate the role and molecular mechanisms of Bruton's tyrosine kinase (BTK), a member of the Tec family in burn sepsis-induced intestinal injury. Eighty C57BL/6 mice were randomly divided into four groups: the sham group, the burn group, the burn + sepsis group, and the burn + sepsis + LFM-A13 (a selective BTK inhibitor) group. The dynamic expression profiles of BTK and p-BTK in the intestine were measured by Western blot analysis. Intestinal histopathological changes and cellular apoptosis were determined. Inflammatory cytokines in serum and intestinal tissue were examined through enzyme-linked immunosorbent assay. Myeloperoxidase (MPO) activity was determined via a colorimetric assay. Intestinal p-BTK expression in the burn+sepsis group was significantly increased compared with that in the sham and burn groups. In the burn + sepsis group, the p-BTK expression level increased over time, peaked at 12, and then decreased at 24 h. LFM-A13 administration significantly inhibited p-BTK expression in the intestine. In contrast to the sham and burn groups, the burn + sepsis group exhibited obvious histopathological changes, which gradually aggravated over time. LFM-A13 also reduced the histopathological changes and cellular apoptosis in intestinal tissues, inhibited the inflammatory cytokines IL-4, IL-6, and TNF-α in serum and intestinal tissues, and significantly inhibited the increase in intestinal MPO activity induced by burn sepsis. BTK activation is one important aspect of the signaling event that may mediate the release of the anti-inflammatory cytokine IL-4 and the pro-inflammatory cytokines IL-6 and TNF-α; oxidative stress; and intestinal cell apoptosis. Thus, it contributes to burn sepsis-induced intestinal injury.

Pediatric Burn Care in the Developing World: Where are the Gaps in Research and What can be Done?

INTRODUCTION

Burns are the fourth most common cause of injury worldwide. The burden of burn injury is largely carried by low and middle-income countries (LMICs) with children in these regions being particularly vulnerable to burns. The purpose of this scoping review is to identify knowledge gaps in global paediatric burn care experience in an effort to help prioritise future research.

METHODS

Using the 6-stage Arksey and O'Malley framework for conducting a scoping review, paediatric burn care literature was reviewed over a ten-year period from 2010 to 2020. Studies from low-resource settings were included and categorised by geographic location, study patient population, study type, type of burn, and level of evidence.

RESULTS

Of 107 included studies, 34% and 49% originated from LMICs in South Asia and Sub-Saharan Africa, respectively. Qualitative/Observational (73%) and Epidemiological Single-Centre (20%) publications comprised the majority of included papers. The majority (95%) of all papers regardless of geographical location were lower levels of evidence (Level 3 or below).

CONCLUSION

Our study identified four primary knowledge gaps: (1) a paucity of high-quality studies to guide burn care in LMICs; (2) an under-representation of articles from certain geographical locations; (3) few therapeutic and economic articles to guide resource allocation; and (4) a lack of articles with long-term patient follow up. Efforts to address these disparities could help reduce the paediatric burn burden of disease in resource-poor settings.

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.

Trapezoid Advancement Flaps for the Treatment of Severe Upper Extremity Burn Contractures Limiting the Risk of Recurrence

INTRODUCTION

Severe postburn contractures can lead to partial or total loss of function of the limbs, with devastating socioeconomic and psychosocial impact on the individual, especially in low- and middle-income countries. We present a surgical technique for the treatment of severe burn contractures with the purpose of limiting recurrence of the contracture after surgery, which was developed based on the observation that in most burn contractures, one side of a contracture has unburnt, soft, and pliable healthy skin. By advancing this skin as a flap over the joint crease, a bridge of healthy tissue is interposed. We postulate that the pliable skin, together with the fact that secondary wound contracture progresses away from the joint in the skin-grafted areas adjacent to the flap and not over a mobile joint, promote healing, prevent skin graft breakdown, and limit recurrence of the contracture in the long term.

METHODS

We retrospectively analyzed data of all patients who have undergone surgery for severe burn contractures of elbow and axilla by means of our technique on the MV Africa Mercy between January 2013 and February 2014.

RESULTS

In 27 patients (19 female, 8 male) with a mean age of 16.4 years, shoulder range of motion improved significantly from preoperative 111.0° to postoperative 149.4° of abduction-adduction. The elbow range of motion improved from preoperative 76.6° to postoperative 108.6° of flexion-extension, with a significant reduction in the residual elbow contracture from 60.5° preoperatively to 18.5° postoperatively. The average follow-up was 3 months (range, 1.5-7 months).

CONCLUSIONS

We conclude that this relatively simple and safe technique limits the risk for early postoperative healing complications and recurrence of the contractures in the long term.

Manufacture and clinical application of the forearm pronation's assistant tableware in the severely burned

INTRODUCTION

Even after reconstructive surgery, it is still difficult for patients with severe burns to achieve independent eating activity. In this project, we customized the forearm pronation's assistant tableware to assist in improvement with eating activities.

METHODS

From January 2017 to December 2018, 28 patients with severe burns including the hands were recruited. For the patient's independent eating activities, we customized forearm pronation's tableware (forks and spoons). We compared modified Barthel index (MBI) and Visual analogue scale (VAS) of satisfaction under three conditions: no auxiliary tableware, ADL universal cuff, or forearm pronation tableware; to compare the duration and the weight of food spilled during lunch when the patients wore the ADL universal cuff or the forearm pronation's tableware. Differences in MBI (rank data) were tested by the Friedman test, differences in VAS (normal distribution) were tested with One-way ANOVA (Bonferroni), differences in the duration and the weight (normal distribution data) were tested by paired sample t test.

RESULTS

After wearing the forearm pronation's assistant tableware, MBI VAS both increased more than when the patients did not wear the auxiliary tableware (all p＜0.05). When the subjects wore forearm pronation tableware, the duration of lunch significantly decreased and the quality of eating activity significantly improved compared to the ADL universal cuff in eating activity (all p＜0.05).

CONCLUSION

After wearing the forearm pronation's assistant tableware, the patients with severe burns completely or almost completely accomplished independent eating, the duration was decreased, and during eating activity the quality and the satisfaction were improved.

CLINICAL TRIAL REGISTRATION

Chinese Clinical trial registry, ChiCTR1800019963.