Pediatric Patients with Postburn Amputations Report Worse Long-term Physical Function but Not Self-Appearance: A Burn Model System Study

Some severe burn injuries may warrant amputation; however, the physical and functional adjustments resulting from postburn amputation can have long-term consequences. This study investigates longitudinal functional and psychosocial outcomes among pediatric burn amputees. Pediatric participants enrolled in the Burn Model System national longitudinal, multicenter database between 2015 and 2023 with postburn amputations were included. Participants with amputations were matched using nearest-neighbor matching to those without amputations based on burn location, age, and % total burn surface area burn size. Primary outcomes were the Patient-Reported Outcomes Measurement Information System Pediatric-25 Profile v2.0 Physical Function and the Children Burn Outcomes Questionnaire: appearance subscore, both measured at 6-, 12-, and 24 months postburn. In this study, 17 participants had amputations, and 17 did not (matched participants). Pairwise analyses at each timepoint found those with amputations reported significantly lower physical function scores at 24 months postburn (54.9 ± 11.6 vs 66 ± 5, P = .013). No significant differences were found in appearance scores. This study suggests that pediatric burn amputees may potentially face greater physical impairment long-term, highlighting an important area of research that deserves further attention.

Higher energy delivery is associated with improved long-term survival among adults with major burn injury: A multicenter, multinational, observational study

BACKGROUND

Numerous feeding strategies have been used to mitigate the catabolism of major burn injury. Whether higher energy and/or protein delivery results in better long-term outcomes is unknown.

METHODS

We performed a secondary analysis of data from adults with major burn injuries enrolled in the Randomized Trial of Enteral Glutamine to Minimize the Effects of Burn Injury at 54 burn centers in 18 countries. The sample was restricted to those who were mechanically ventilated within 72 hours of injury and for ≥7 days. Our key exposure was adequacy of energy, and protein ([Delivered i /Prescribed i ] × 100) was categorized into three groups each: low, 0% to 50%; moderate, ≥50% to 79%; and high, ≥80%. We also analyzed adequacy using restricted cubic splines. Primary and secondary outcomes included 6-month mortality and functional outcomes (i.e., 36-Item Short-Form Health Survey, Katz Index of Independence in Activities of Daily Living, Lawton Activities of Daily Living scores), respectively. Regression models were adjusted for age, body mass index, Charlson Comorbidity Index, baseline Acute Physiology and Chronic Health Evaluation II and modified Sequential Organ Failure Assessment scores, burn size, energy/protein adequacy, and study site.

RESULTS

A total of 493 participants met the cohort restriction criteria; 336 participants were alive at 6 months. 36-Item Short-Form Health Survey, Katz Index of Independence in Activities of Daily Living, and Lawton Instrumental Activities of Daily Living Scale were completed by 218, 216, and 215 participants, respectively. The mean ± SD age was 48 ± 17 years, and 74% were male. The mean ± SD burn size was 41% ± 18% total body surface area. Participants who received 25% of recommended calories had nearly four times the hazard of death during the 6-month follow-up period than participants who received 100% of prescribed calories (adjusted hazard ratio, 3.89; 95% confidence interval, 1.35-11.20) ( p = 0.02). There was no significant association between protein and 6-month mortality or energy/protein delivery and 6-month functional outcomes.

CONCLUSION

There was a positive association between higher doses of energy and 6-month survival. This relationship conflicts somewhat with several energy studies among critically ill and non-burn-injured patients. The lack of consistent evidence on optimal nutrition for critically injured patients, a fundamental component of burn care, suggests potential for a randomized trial of lower versus higher energy to improve long-term outcomes after burn injury.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

An increase in electrical burns during the covid lockdown in Western Cape, South Africa

BACKGROUND

A severe Covid lockdown in South Africa may have changed burn patterns due to the downturn of the economy and stay-at-home policies. We describe the volume and type of burn admitted to a tertiary hospital before and during the Covid lockdown.

MATERIALS AND METHODS

This was a retrospective study from before (April 2019-March 2020) and during (April 2020-March 2021) the Covid pandemic. Patient demographics, burn etiology, and clinical outcomes were described. Logistic regression was used to model associations between burn etiology and the Covid period.

RESULTS

Of 544 burns, 254 (46.7%) occurred before and 290 (53.3%, p = 0.051) during Covid. The proportion of electrical burns doubled during Covid n = 20, 32.3% vs n = 42, 67.7%, (p = 0.053) periods. At least half were associated with suspected cable or copper theft. On multivariate analysis, flame burns (OR=2.42, p < 0.001), electrical burns (OR=4.88, p < 0.001), and paying patients (OR=4.21, p < 0.001) were more likely to be associated with the Covid period.

CONCLUSION

Electrical burns doubled during Covid, potentially related to an increase in cable and copper wire theft, a phenomenon described during hard economic times in other settings. More studies to understand this potential relationship are indicated to prepare burn centers during future pandemics and/or economic hardship.

Physiotherapy Approach in Transradial Amputation Following the Sequelae of Electric Burn: A Case Report

A considerable amount of mortality and morbidity has been attributed to burn injuries. Because of expanding industrial development, greater consumption of electricity, and electric appliances at home, the number of burns caused by electricity is expanding. When it pertains to addressing burn injuries, therapeutic pursuits are necessary. The 18-year-old female patient in this case reported a history of burns due to electrical shock to her left upper and lower limbs along with her right foot. She came to the hospital, and after necessary investigations and examination, she was suggested for below elbow amputation or transradial amputation with debridement of the wound over the left axilla, foot, and right foot. Following the surgical procedure, the patient had pain, reduced muscle strength, limited joint mobility, and edema. For further rehabilitation, community health physiotherapy was advised. Routine physiotherapy treatment was provided to the patient for fifteen days. We report that after surgery, the effects of physical therapy showed decreased pain intensity, enhanced range of motion (ROM) of the affected and peripheral joints, and improved strength in adjacent muscles.

Return-to-employment for working-aged adults after burn injury: A mixed methods scoping review

BACKGROUND

This scoping review aimed to identify the barriers, facilitators and benefits of returning to work following burn injury, outcome measures used, management strategies, and models of care.

OBJECTIVE

To provide a comprehensive overview about working-aged adults returning to their preinjury employment after burn injury.

METHODS

We followed a pre-determined scoping review protocol to search MEDLINE, CINAHL, Embase, PsycINFO, PubMed, Scopus, CCRCT and CDSR databases between 2000 to December 2023. Papers reporting primary data from previously employed adults with cutaneous burn injuries were included.

RESULTS

In all, 90 articles met the review criteria. Return-to-work was both an outcome goal and process of recovery from burn injury. Physical and psychological impairments were identified barriers. Job accommodations and modifications were important for supporting the transition from hospital to workplace. Employment status and quality of life sub-scales were used to measure return-to-work.

CONCLUSIONS

Consistent definitions of work and measurements of return-to-employment after burn injury are priorities for future research. Longitudinal studies are more likely to capture the complexity of the return-to-employment process, its impact on work participation and changes in employment over time. The social context of work may assist or hinder return-to-work more than physical environmental constraints. Equitable vocational support systems would help address disparities in vocational rehabilitation services available after burn injury.

Burn Injury Complications Impacting Rehabilitation

Successful post-burn rehabilitation requires an understanding of a wide range of complications to maximize functional recovery. This article reviews a range of potential challenges including burn scar contracture, amputation, peripheral nerve injury, heterotopic ossification, dysphagia, altered skin physiology, pain, and pruritis. The overall focus is to serve as a guide for post-injury therapy and rehabilitation spanning the phases of care and considering evidence-based approaches, prevention, and treatment with an ultimate goal of aiding in the functional recovery and long-term quality of life for burn survivors.

Burn Center Patients at Risk for Upper Extremity Amputations

Introduction Burn center patients present not only with burn injuries but also necrotizing infections, purpura fulminans, frostbite, toxic epidermal necrolysis, chronic wounds, and trauma. Burn surgeons are often faced with the need to amputate when limb salvage is no longer a viable option. The purpose of this study was to determine factors which predispose patients to extremity amputations. Methods: This retrospective registry review (2000-2019) compared patients who required upper extremity amputations with those who did not. Cases were pair-matched by age, sex, percent total body surface area (%TBSA), and type/location of injury to control for possible confounding variables. Results: There were 77 upper extremity amputee patients (APs) and 77 pair-matched non-amputees (NAPs) with the median age 45- and 43-years, %TBSA 21 and 10, respectively; second and third degree burn injuries were similar in the 2 groups. The AP group had longer hospitalizations (median 40 vs 15 days) P < .0001, with more intensive care unit days (median 28 vs 18 days). APs presented with significantly more cardiac, renal, and pulmonary comorbidities, acquired infections (61 [64%] vs 35 [36%]), escharotomies, and fasciotomies than the NAP, P < .0001. Mortality was similar (AP 14 [18.2%] vs NAP 9 [11.7%]), P = .26. Conclusions: Escharotomies, fasciotomies, sepsis, pneumonia, wound, and urinary tract infections contributed to prolonged hospitalizations and increased risk for upper extremity amputations in the AP group.

Long-Term Outcomes in Burn Patients

Better understanding of long-term outcomes after burn injury is essential for the burn clinician. Contractures are present in almost half of patients at discharge. Although less common, neuropathy and heterotopic ossification may be missed or go unaddressed. Close attention to psychological distress and to challenges with community reentry is essential. Obviously long-term problems with skin issues occur but other issues must be attended to maximize health and quality of life after injury. Facilitating access to community resources and providing long-term medical follow-up should be the standard of care.

Are burns a chronic condition? Examining patient reported outcomes up to 20 years after burn injury-A Burn Model System National Database investigation

BACKGROUND

People living with burn injury often face long-term physical and psychological sequelae associated with their injuries. Few studies have examined the impacts of burn injuries on long-term health and function, life satisfaction, and community integration beyond 5 years postinjury. The purpose of this study was to examine these outcomes up to 20 years after burn injury.

METHODS

Data from the Burn Model System National Longitudinal Database (1993-2020) were analyzed. Patient-reported outcome measures were collected at discharge (preinjury status recall) and 5 years, 10 years, 15 years, and 20 years after injury. Outcomes examined were the SF-12/VR-12 Physical Component Summary and Mental Component Summary, Satisfaction with Life Scale, and Community Integration Questionnaire. Trajectories were developed using linear mixed models with repeated measures of outcome scores over time, controlling for demographic and clinical variables.

RESULTS

The study population included 421 adult burn survivors with a mean age of 42.4 years. Lower Physical Component Summary scores (worse health) were associated with longer length of hospital stay, older age at injury and greater time since injury. Similarly, lower Mental Component Summary scores were associated with longer length of hospital stay, female sex, and greater time since injury. Satisfaction with Life Scale scores decrease negatively over time. Lower Community Integration Questionnaire scores were associated with burn size and Hispanic/Latino ethnicity.

CONCLUSION

Burn survivors' physical and mental health and satisfaction with life worsened over time up to 20 years after injury. Results strongly suggest that future studies should focus on long-term follow-up where clinical interventions may be necessary.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.

Amputations secondary to burn injuries in a resource-limited setting

INTRODUCTION

Amputations are a devastating consequence of severe burns. Amputations in a resource-limited setting are challenging as rehabilitation services available to these patients are inconsistent and often fragmented. Epileptic patients are a particularly vulnerable group when it comes to burn-injuries and often sustain deeper burns. The aim of this study is to analyse amputations secondary to burn injuries. We seek to identify vulnerable groups as a means for advocacy efforts to reduce the devastation of an amputation secondary to a burn injury. This paper highlights the burden of these injuries on the healthcare system and emphasizes the need for additional trained therapists for the rehabilitation of these patients.

METHODS

A retrospective database review was conducted. All burns admissions who underwent an amputation between 1 February 2016 and 31 January 2019 were considered.

RESULTS

A total of 1575 patients were admitted during the study period. Fifty-four percent of the admissions were paediatric patients. The amputation rate in the paediatric population was 1.5% (13/850) while in the adult population it was 4.8% (35/724) . Most paediatric amputations were as a result of electrical injuries. Flame burns were most likely to result in amputations in the adult group and convulsions were the leading circumstance leading to the injury. There was no significant difference in sepsis or length of stay between the groups. There were no mortalities in the paediatric group but there was an 11% mortality rate in the adult group.

CONCLUSION

The incidence of amputations in burns is low, however, it remains a devastating morbidity. Epileptics are a vulnerable group and these patients account for the most amputations among adult burns patients. Education interventions are needed regarding their diagnosis, administration of their medication and the importance of compliance. Advocacy efforts to ensure constant supply of anti-epileptic drugs at the clinics and other district level health facilities is also essential. Electrical injuries in children are not as common as hot water scalds, however, they are more likely to result in amputation. Communities need to be informed of the risk associated with illegal electrical connections and initiatives need to drive the safe provision of affordable electricity to these under-privileged, vulnerable communities.

Measuring socioeconomic outcomes in trauma patients up to one year post-discharge: A systematic review and meta-analysis

INTRODUCTION

Trauma accounts for nearly one-tenth of the global disability-adjusted life-years, a large proportion of which is seen in low- and middle-income countries (LMICs). Trauma can affect employment opportunities, reduce social participation, be influenced by social support, and significantly reduce the quality of life (QOL) among survivors. Research typically focuses on specific trauma sub-groups. This dispersed knowledge results in limited understanding of these outcomes in trauma patients as a whole across different populations and settings. We aimed to assess and provide a systematic overview of current knowledge about return-to-work (RTW), participation, social support, and QOL in trauma patients up to one year after discharge.

METHODS

We undertook a systematic review of the literature published since 2010 on RTW, participation, social support, and QOL in adult trauma populations, up to one year from discharge, utilizing the most commonly used measurement tools from three databases: MEDLINE, EMBASE, and the Cochrane Library. We performed a meta-analysis based on the type of outcome, tool for measurement, and the specific effect measure as well as assessed the methodological quality of the included studies.

RESULTS

A total of 43 articles were included. More than one-third (36%) of patients had not returned to work even a year after discharge. Those who did return to work took more than 3 months to do so. Trauma patients reported receiving moderate social support. There were no studies reporting social participation among trauma patients using the inclusion criteria. The QOL scores of the trauma patients did not reach the population norms or pre-injury levels even a year after discharge. Older adults and females tended to have poorer outcomes. Elderly individuals and females were under-represented in the studies. More than three-quarters of the included studies were from high-income countries (HICs) and had higher methodological quality.

CONCLUSION

RTW and QOL are affected by trauma even a year after discharge and the social support received was moderate, especially among elderly and female patients. Future studies should move towards building more high-quality evidence from LMICs on long-term socioeconomic outcomes including social support, participation and unpaid work.

Most prominent factors contributing to burn injury-related amputations: an analysis of a referral Burn Center

Amputations are un-common surgical procedures in patients with severe burn injuries. However, these patients often face extreme physical and psychological challenges that result in social stigmatization and inadequate rehabilitation facilities. A retrospective cohort study was designed for the patients admitted to the Burn Center of Adana City Training and Research Hospital (ACTRH). During the study period, a total of 2007 patients aged 0.5 to 92 years were hospitalized and treated at the burn center from January 2016 to June 2020. The incidence of amputation observed among inpatient burn injuries regardless of the etiology was 1.9%, and 87.2% were male. The univariate and multivariate logistic regression analysis was performed to detect the most prominent factors contributing to burn injury-related amputations. The cause of burns appears to be one of the main factors in the past research, and in this context, the electrical burns stand out, likewise, the fire-flame-related burns, full-thickness burns, the existence of infection, male gender, patients aged within the 18 to 64 age group, and the burn extent within the total body surface area (TBSA) range of 10 to <50% were found to be the most leading factors of amputations among patients having severe burns. Although they are rare, amputations related to burns commonly cause a decrease in quality of life. Therefore, besides increasing occupational health and safety methods for these risk groups, especially for adults of working age; also, it is essential to increase the importance and awareness of the precautions to be taken in daily life.

"Living Well" After Burn Injury: Using Case Reports to Illustrate Significant Contributions From the Burn Model System Research Program

The Burn Model System (BMS) program of research has been funded since 1993 by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). The overarching aim of this program is to improve outcomes and quality of life for people with burns in the areas of health and function, employment, and community living and participation. This review reports on BMS contributions that have affected the lives of individuals with a significant burn injury using case reports to associate BMS contributions with recovery. In January 2020, current BMS grantee researchers assessed peer-reviewed BMS publications from 1994 to 2020. Using case report methodology, contributions were linked to three individuals treated at one of the four Burn Model System institutions. With over 25 years of NIDILRR funding, unique BMS contributions to patient recovery were identified and categorized into one of several domains: treatment, assessment measures, sequelae, peer support, employment, and long-term functional outcomes. A second review for significant results of BMS research that add to the understanding of burn injury, pathophysiology, and recovery research was identified and categorized as injury recovery research. The case study participants featured in this review identified select NIDILRR research contributions as having direct, personal benefit to their recovery. The knowledge generation and clinical innovation that this research program has contributed to our collective understanding of recovery after burn injury is considerable. Using case study methodology with three adult burn survivors, we highlight the impact and individual significance of program findings and reinforce the recognition that the value of any clinical research must have relevance to the lives of the study population.

Predictive Factors for Returning to Work in Burn Adult Patients That Were Working Before Their Injury

The goal of this study was to identify predictive factors that influence return to work in burn patients treated at the National Center for Burn Care and Research at the National Institute of Rehabilitation (CENIAQ) in México City. This is a retrospective case-control study that included all burn patients of working age (16-91 years old), treated between January 2011 and December 2013. Patients were divided into two groups: unemployed (no work group) and those who returned to work (RTW). The statistical analysis was performed by a logistic regression univariate and multivariate analysis. A total of 210 subjects were included in the study. The mean age was 38 ± 15 years and 66.7% of them were male. One hundred sixty-five patients (79.6%) were able to return to work after treatment. Through univariate analysis it was found that the predictive factors for not returning to work after injury were: education lower than elementary school (OR: 3.59; CI 95%: 1.79-7.32); history of epilepsy prior to burn injury (OR: 10.18; CI 95%: 1.9-54.43); total burned surface area (TBSA) ≥20% (OR: 2.87; CI 95%: 1.46-5.64); third-degree burns (OR: 2.64; CI 95%: 1.32-5.29); hospital stay ≥20 days (OR: 2.8; CI 95%: 1.47-5.68); length of stay in the burn intensive care unit (OR: 2.5; CI 95%: 1.25-4.97); secondary infection (OR: 2.24; CI 95%: 1.15-4.38); amputations (one or more regardless of amputation level; OR: 8; CI 95%: 2.52-25.30); burn of the upper extremity (shoulder; OR: 2.21; CI 95%: 0.97-5.03); thigh (OR: 2.41; CI 95%: 1.32-5.14); and knee (OR: 2.81; CI 95%: 1.21-6.55). Some of these factors have never been reported by other authors.

Amputation Following Burn Injury

Amputation following burn injury is rare. Previous studies describe the risk of amputation after electrical burn injuries. Therefore, we describe the distribution of amputations and evaluate risk factors for amputation following burn injury at a large regional burn center. We conducted a retrospective analysis of patients ≥17 years admitted from January 2002 to December 2015. Patients who did and did not undergo an amputation procedure were compared. A multivariate logistic regression model was used to determine the risk factors for amputation. Amputations were further categorized by extremity location and type (major, minor) for comparison. Of the 8313 patients included for analysis, 1.4% had at least one amputation (n = 119). Amputees were older (46.7 ± 17.4 years) than nonamputees (42.6 ± 16.8 years; P = .009). The majority of amputees were white (47.9%) followed by black (39.5%) when compared with nonamputees (white: 57.1%, black: 27.3%; P = .012). The most common burn etiology for amputees was flame (41.2%) followed by electrical (23.5%) and other (21.9%). Black race (odds ratio [OR]: 2.29; 95% confidence interval [CI]: 1.22-4.30; P = .010), electric (OR: 13.54; 95% CI: 6.23-29.45; P < .001) and increased %TBSA (OR: 1.03; 95% CI: 1.02-1.05; P < .001) were associated with amputation. Burn etiology, the presence of preexisting comorbidities, black race, and increased %TBSA increase the odds of post burn injury. The role of race on the risk of amputation requires further study.

Burn survivors' perception of recovery after injury: A Northwest Regional Burn Model System investigation

INTRODUCTION

Previous reports suggest that many factors impact recovery from burn injury. To improve our understanding of these factors, we queried adult burn survivors using a mixed method design during the first year after injury.

METHODS

An anonymous, 2-page survey was developed and administered to adult burn survivors during routine outpatient clinic follow-up visits at a regional burn center. Participants rated issues of concern and their impacts on return to pre-burn activity levels. Both quantitative and qualitative data were obtained. Descriptive statistics were used to analyze quantitative data and thematic analysis was used to identify, analyze and report patterns from open-ended responses.

RESULTS

Over seven months in 2016, 187 patients completed the anonymous survey. Study participants were predominantly male, white, and non-Hispanic. Participants who had not yet returned to pre-burn function reported worse outcomes for all issues queried compared to those who had. Burn survivors from racial and ethnic minority groups reported greater difficulty with accessing medical care and information about their injury as well as higher levels of self-identified posttraumatic stress, issues related to appearance and concerns for loss of strength. Several themes and sub-themes were identified that had both negative and positive impact on early recovery. Such themes included: healing process, psychological recovery and emotional health, and community reintegration/employment.

CONCLUSIONS

Several themes from responses provided insight into challenges as well as key support systems during the first year of recovery after injury. Collectively, these findings can be used to direct clinical outpatient care, patient education and psychosocial support services.