The role of seizure disorders in burn injury and outcome in Sub-Saharan Africa

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.

Disability assessment among persons with epilepsy in Mahenge, an onchocerciasis-endemic area in Tanzania: A cross-sectional study

BACKGROUND

A high prevalence of epilepsy has been observed in the onchocerciasis-endemic focus of Mahenge, Tanzania. This study sought to assess the degree of disability experienced by persons with epilepsy (PWE) in Mahenge and identify associations with sociodemographic and clinical features.

METHOD

This cross-sectional study was conducted in Mahenge, Tanzania, between February and July 2020. PWE were recruited from the Mahenge epilepsy clinic and four neighbouring rural villages (Mdindo, Mzogezi, Mzelezi and Sali). Data were collected using the 36-item version of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) questionnaire for adults. For children aged 5-17 years, we used the Module on Child Functioning developed by UNICEF and the Washington Group. Questionnaires were administered by trained research assistants. Descriptive statistics were performed, and multivariable analyses (gamma and logistic regressions) were conducted.

RESULTS

A total of 321 adults (45.5% males) and 48 children (55.3% males) with epilepsy participated. The overall median WHODAS 2.0 score was 4.8% (IQR: 0.9-18.9). The most affected disability domain was 'participating in the society' (median score: 12.5%, IQR: 0-29.2). Fifteen (31.3%) of the children with epilepsy had a disability in at least one domain of the child functioning module, with the 'accepting change' domain harbouring the highest proportion of disabled children (12.5%). Higher seizure frequency and longer epilepsy duration were associated with more disability.

CONCLUSION

PWE in Mahenge experience variable degrees of disability. The affected domains indicate the need for societal rehabilitation of PWE in various community and/or social activities. Peer-support groups were instituted at the study sites to address these needs.

Sex-Related Mortality After Burns: A Scoping Review in the Sadc-Region

Findings on mortality by sex after burns in low- and middle-income countries (LMICs) are contradictory and, where differences have been described, the reasons are often based on speculation and not on the analysis of factors that could have affected the outcome, such as patient or injury characteristics or provided care. Since the paucity of studies on burns from single LMICs is notorious, merging data from neighboring countries with similar socio-economic backgrounds might provide a larger dataset, contributing to identifying recurrent causes. This scoping review aimed therefore to analyze differences in mortality after burns between the sexes, as well as to identify aspects that could explain possible differences, in countries belonging to the South African Development Community (SADC) region. Studies in English published between 2010 and 2020 were identified according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines by searching PubMed and/or Medline, Clinical Trials and Cochrane Library, and using the screening tool "Covidence". The 13 included studies could not consistently show association between sex and mortality after burns, but contradictory findings. In the case of differences in outcome between the sexes, explanations were mainly based on speculation (e.g., hormonal differences, self-harm intention), while rarely burn specific factors were reported and included in the analysis of the mortality risk. This study indicates the need for prospective burn specific data collection in LMICs that would contribute to identifying factors associated with death.

A plastic and reconstructive surgery landscape assessment of Malawi: a scoping review of Malawian literature

BACKGROUND

Plastic and reconstructive surgery (PRS) remains highly relevant to the unmet need for surgery in Malawi. Better understanding the current PRS landscape and its barriers may help address some of these challenges. This scoping review aimed to describe: (1) the scope and focus of the PRS literature being produced in Malawi and (2) the challenges, deficits, and barriers to providing accessible, high-quality PRS in Malawi.

METHODS

This scoping review was conducted on four databases (SCOPUS, PubMed, Web of Science, EMBASE) from inception through September 1, 2020 following the PRISMA-ScR guidelines.

RESULTS

The database search retrieved 3852 articles, of which 31 were included that examined the burden of PRS-related conditions in Malawi. Of these 31 articles, 25 primarily discussed burn-related care. Burns injuries have a high mortality rate; between 27 and 75% in the studies. The literature revealed that there are only two burn units nationally with one PRS specialist in each unit, compounded by a lack of interest in PRS specialization by Malawian medical students. Congenital anomalies were the only other PRS-related condition examined and reported in the literature, accounting for 23% of all pediatric surgeries in tertiary facilities.

CONCLUSIONS

There is a need to increase the country's capacity to handle burn reconstruction and other PRS-related conditions to reduce overall morbidity and mortality. Additional publicly funded research at the district and community level is warranted to determine the true burden of PRS disease in Malawi to derive health system strengthening and workforce capacity building strategies.

Epilepsy in a health district in North-West Cameroon: Clinical characteristics and treatment gap

INTRODUCTION

Epilepsy is a common yet misunderstood condition in Cameroon, including in the Batibo Health district.

METHODS

This cross-sectional study describes epilepsy clinical characteristics, the treatment gap, and associated factors in a rural district in Cameroon. After screening for epilepsy using a door-to-door survey, physicians confirmed suspected cases of epilepsy. Detailed information on the medical, seizure, and treatment history was collected from everyone with epilepsy, followed by a general and neurological examination.

RESULTS

We diagnosed 546 people with active epilepsy (at least one seizure in the previous 12 months). The mean age of people with active epilepsy was 25.2 years (SD: 11.1). The mean age at first seizure was 12.5 years (SD: 8.2). Convulsive seizures (uncertain whether generalized or focal) were the most common seizure types (60%), while 41% had focal-onset seizures. About 60% of people had seizures at least monthly. One-quarter of participants had had at least one episode of status epilepticus. Anti-seizure medication (ASM) was taken by 85%, but most were receiving inappropriate treatment or were non-adherent, hence the high treatment gap (80%). Almost a third had had seizure-related injuries. Epilepsy was responsible for low school attendance; 74% of school dropouts were because of epilepsy.

CONCLUSION

The high proportion of focal-onset seizures suggests acquired causes (such as neurocysticercosis and onchocerciasis, both endemic in this area). The high epilepsy treatment gap and the high rates of status epilepticus and epilepsy-related injuries underscore the high burden of epilepsy in this rural Cameroonian health district.

Influence Of Pre-Existing Neurological Illnesses On The Outcome Of Severe Burn Injuries

It is known that patients suffering from neurological illnesses have an increased risk of burn injuries. These burns are often very severe and lead to poor outcomes. To date, only a few studies have evaluated the impact of pre-existing neurological illnesses on the outcome of burn injuries. None of them performed a regression analysis regarding specific influence on mortality. Between 1996 and 2016, 1475 patients were admitted to the BICU of a specialized German burn center: 26 had less than 1% TBSA burned and were excluded; 177 had pre-existing neurological disorders (group N). 87 patients with psychological disorders were excluded. 1185 patients without neurological or psychological disorders formed the control group. Length of hospital stay, TBSA and number of operations were analyzed using the chi-squared test and Mann-Whitney U-test. Additionally, mortality was evaluated using the logistic regression analysis adjusted for known outcome predictors. Mean age of the patients in the control group was 41.53 years with a BICU stay of 18 days, TBSA of 18.25% and mortality rate of 12.4%; 23.7% had inhalation injuries. Patients in group N had a mean age of 54.63 years, a BICU stay of 27 days, mean TBSA of 20.97%; 31.1% had inhalation injuries and mortality was 20.3%. Patients with neurological disorders were older and showed higher affected TBSA, higher rates of inhalation injury, mortality and affected TBSA, and a longer stay in the BICU compared to the control group. Nevertheless, pre-existing neurological disorders alone had no significant influence on mortality.

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Patients with epilepsy are a high-risk population for severe burns. A retrospective study was conducted to assess burns during epileptic seizure in epileptic patients. The study was conducted in a 20- bed burn ICU in Tunis over the period 01/01/2011 to 30/06/2019. Fifty cases combining burns and epilepsy were reviewed. Twenty patients (11 women and 9 men, sex-ratio 0.6) suffering a burn following an epileptic seizure were included. The average age was 46. Epileptic disease was uncontrolled in 75% of our patients and 35% were not receiving any antiepileptic treatment. Burns were related to domestic accident in 95% of cases, 2/3 of which were related to a fall on a brazier. Lesions were deep in 70% of cases, requiring excision of necrotic tissue. Only two patients benefited from a dermal-epidermal graft. Amputation was necessary in 5 patients. Mortality was 25%, related to refractory septic shock.

Evaluation of epilepsy and burn patterns in a tertiary hospital in southwestern Iran

PURPOSE

Based on the high rates of burn injuries in patients with epilepsy, it is crucial to evaluate the epidemiological factors, etiology, types of burns, and outcome of these certain individuals and to enhance knowledge about the possible risks of epilepsy-related burns by preventive actions and programs.

METHOD

Our retrospective study was carried out from September 2013 to February 2017 in Amir-al Momenin Hospital, a tertiary referral burns and plastic surgery healthcare center. Because of the fact that a number of patients with burns had experienced their trauma at the time of convulsion or in postconvulsion phase, it is necessary to evaluate the outcome, burn patterns, etiology of injury, and related epidemiological factors in order to develop a greater understanding of possible risks of epilepsy-related burns by preventive actions and programs.

RESULT

In our study, 2715 patients who referred to burn centers and hospitalized with a mean age of 26.838 (standard deviation (SD) = 21.186) were enrolled, in which 29 patients were involved in burn accidents due to epilepsy and seizure, resulting in a 1.1% epilepsy incidence in these individuals. In patients with seizure disorder, there was a mean rate of 5.8 (SD = 1.923) cases per year. Eighteen (62.1%) were male, and 11 (37.9%) were female. There were no cases of seizure-induced burn injury in pediatrics (<15 years) in our study. Among the patients with seizure-induced burns, 11 (out of 1101; 37.9%) were from rural areas, while 18 (out of 1570; 62.1%) were from urban locations. The occurrence of accidents due to seizure was also categorized based on the season, with the highest occurrence during winter (12 out of 683; 41.4%) and lowest during spring (3 out of 659; 10.3%). The mechanism of burn in patients with seizures was also documented, in which 12 (41.4%) were due to liquid, 12 (41.4%) due to fire, 1 (3.4%) due to explosion, and 1 (3.4%) due to other objects. Out of patients with seizure-induced burns, 21 (72.4%) were discharged, 2 released with their own will, 1 was transferred, and 5 (17.2%) died in the course of hospitalization.

CONCLUSION

This study demonstrates that burn injuries by epilepsy are a public health concern in low- and middle-income countries. Therefore, we suggest the execution of a strong national epilepsy preventive actions and programs, as well as proper education for both medical practitioners and patients of the possible dangers as part of an injury control program.

The Global Burn Registry: A Work in Progress

In 2018, the World Health Organization (WHO) launched the Global Burn Registry (GBR). Its purpose is to help improve the understanding of burn injury worldwide. The purpose of this study was to identify early findings from this database. The GBR was accessed on January 5, 2020. Cases from centers in low income (LIC) and low-middle-income countries (LMIC) were combined into a low resource (LR) group, and cases in high income (HIC) and upper-middle-income countries (UMIC) were combined into a high resource (HR) group. Statistical analysis was performed with SAS 9.4. Data are expressed as mean ± SEM. Logistic regression was used to identify risk factors for death. Revised Baux Score (RBS) was calculated. Odds ratios are expressed as mean (95% confidence interval). The LA50 was calculated from the regression of death and total burn size (TBSA) for different age groups. At the time of analysis, there were 4307 cases in the GBR treated at 28 facilities in 17 countries (5 HIC, 5 UMIC, 4 LMIC, and 3 LIC). There were 2945 cases (68%) from HR countries and 1362 (32%) from LR countries. The mean age of patients in both LR and HR was similar (24.5 ± 0.5 vs 24.2 ± 0.4 years, P = .58), but LR had larger TBSA burns (30.5 ± 0.7% vs 19.8 ± 0.4% TBSA, P < .0001). There were fewer scald burns and more flame injuries in the LR countries (28.4 ± 1.3% vs 43.3 ± 1.0% and 55.2 ± 1.4% vs 39.0 ± 0.9%, P < .0001). Case fatality and RBS were greater in LR (31.9 ± 1.3% vs 9.4 ± 0.5% and 59.4 ± 1.1% vs 45.3 ± 0.6%, P < .0001). In regression analysis, LR was an independent risk factor for death with an odds ratio of 4.2 (3.2-5.4). The LA50 for HR countries was similar to that calculated from cases in the National Burn Repository of the American Burn Association (ABA NBR). For LR countries, the LA50 was lower for all ages except those 65 and older, ranging from 30% to 43% TBSA. Only a few facilities have contributed data to the GBR so far, with LR countries less represented than HR ones. The proportion of cases in the pediatric age group is much less represented in LR countries than in HR, possibly because many burned children in LR countries do not get burn care at specialized centers. Survival in HR countries is similar to that in North America. The GBR provides early insights into global burn care. Opportunities for improvement are greatest in LR countries. New Innovations may be necessary to increase participation from burn centers in LR countries. This report provides an early look at burn care across the globe based on cases in the GBR. It may inform further efforts to characterize and improve burn care in LR countries.

Association Between Attention Deficit Hyperactivity Disorder and Risk of Burn Injury: A Propensity-Matched Cohort Study

PURPOSE

Literature suggests that attention deficit hyperactivity disorder (ADHD) is associated with a high risk of unintentional injury. However, few studies have focused on whether risk of burn injury is relatively high among patients with ADHD. The aim of this study was to investigate whether ADHD affects the risk of burn injury.

MATERIALS AND METHODS

Individuals aged <18 years with a current diagnosis of ADHD (N = 52,705) and age-, sex-, and other comorbidity-matched controls were selected from Taiwan's National Health Insurance Research Database for the period of January 1996 to December 2013. Burn injury was identified in both groups, and risk was evaluated using Cox proportional hazards models. We also explored the effects of age and sex on the association.

RESULTS

We determined that patients with ADHD had an increased probability of burn injury compared with the control group (ADHD vs controls, 4.6% vs 2.6%; adjusted hazard ratio [aHR] = 1.78; 95% confidence interval [CI] = 1.66-1.90). The effect of ADHD on burn injury was more prominent among those aged <6 years (aHR = 1.96; 95% CI = 1.75-2.20) relative to those aged ≥6 years (aHR = 1.69; 95% CI = 1.56-1.83). Both sexes had similar risk profiles.

CONCLUSION

The study findings contribute to the increasing body of evidence that ADHD is associated with proneness to burn injury, particularly in children aged <6 years.

The Effect of Pre-existing Seizure Disorders on Mortality and Hospital Length of Stay Following Burn Injury

Patients with a seizure disorder have a higher incidence of burn injury; however, there are limited studies that examine the association between pre-existing seizure disorders (PSD) and burn outcomes. This is a retrospective study of admitted burn patients. Variables analyzed include patient demographics, clinical characteristics, associated PSD, hospital length of stay (LOS), and mortality. Multivariate logistic regression was performed to analyze the impact of PSD on burn mortality and LOS. Seven thousand six hundred and forty patients met the inclusion criteria and 1.31% (n = 100) patients had a PSD. There was no difference in mortality rate between patients with or without PSD (odds ratio [OR] = 2.28, 95% confidence interval [CI] = 0.87 to 5.93). Multivariate logistic regression showed that patients with PSD had significantly increased odds of longer hospital LOS (OR = 2.85, 95% CI = 1.73 to 4.67). Seizure disorder management is mandatory in reducing burn injury and decreasing the costs associated with increased hospital LOS.

Bridging the childhood epilepsy treatment gap in northern Nigeria (BRIDGE): Rationale and design of pre-clinical trial studies

Epilepsy is the most common serious childhood neurological disorder. In the low- and middle-income countries (LMICs) of Africa, children with epilepsy suffer increased morbidity and mortality compared to their counterparts in high-income countries, and the majority do not receive treatment - the childhood epilepsy treatment gap. Reports of the childhood epilepsy treatment gap in Africa are likely underestimates; most surveys do not include several common childhood seizure types, including most types of non-convulsive epilepsy. Efforts to scale up childhood epilepsy care services in the LMICs of Africa must contend with a shortage of physicians and diagnostic technology [e.g., electroencephalograms (EEGs)]. One pragmatic solution is to integrate epilepsy care into primary care by task-shifting to community health extension workers. The aims of this project (BRIDGE) are to: 1) train, develop, and pilot task-shifted epilepsy care teams; 2) develop and pilot innovative childhood epilepsy screening and diagnostic paradigms adapted to the local Hausa language/culture in Kano, northern Nigeria; and, 3) quantify and map the childhood epilepsy treatment gap, using geographic information systems (GIS), to target limited resources to areas of greatest need. Task-shifted teams will diagnose and manage childhood epilepsy using an innovative epilepsy screening tools and diagnostic and management paradigms in environments with limited EEG access. If validated and demonstrated efficacious in clinical trials, this project can be taken to scale across broader areas of west Africa's LMICs that share language and culture. BRIDGE has the potential to enhance access to basic childhood epilepsy care and establish the foundation for childhood epilepsy clinical trials in west Africa.

Burn: A Predictable but Preventable Tragedy in Epileptic Patients

BACKGROUND

Epilepsy, the world's most common neurological brain dysfunction, affects more than 50 million people worldwide. Burn injuries can be the leading cause of morbidity and mortality in the patients. This study assessed the predictable but preventable tragedy in epileptic burn patients.

METHODS

From January 2001 to January 2011, data included patient's demographic, burn cause, Total Body Surface Area (TBSA) of the burn injury, patient's risk awareness, the type of treatment required as well as the treatment outcome were collected from burn admissions. Totally, 39 patients who sustained burn injuries due to epileptic seizures w were enrolled.

RESULTS

Totally, 39 (1.7%) were epileptic with mean age of 30±11 years, 51.3% were female, 41.2% were single and 53.84% were rural residents and 12.8% had academic education. The majority of the thermal injuries occurred at home (82.1%). Flame was the most common cause of burn (66.7%). The mean Total Body Surface Area was 19.69±18.25. Finally, 38 patients were discharged with mortality rate of 2.6%. Thirty patients underwent split or full thickness graft as the most common surgery. Only 5 patients were aware of the burn injury risk during seizure attack.

CONCLUSION

Despite reduction in burn injuries secondary to seizure, still such injuries lead to significant morbidity and mortality. Since these patients should adhere to specific medication, controlling it remains to be difficult. So preparation for preventive strategies is consisted of life style modification along with patients' education that is further warranted.

Qualitative analysis of a psychological supportive counseling group for burn survivors and families in Malawi

OBJECTIVE

While psychological care, including supportive group therapy, is a mainstay of burn treatment in the developed world, few reports of support groups for burn survivors and their caregivers in the developing world exist. This study records the findings of a support group in Malawi and provides a qualitative analysis of thematic content discussed by burn survivors and caregivers.

MATERIALS AND METHODS

We established a support group for burn survivors and caregivers from February-May 2012 in the burn unit at Kamuzu Central Hospital in Lilongwe, Malawi. Sessions were held weekly for twelve weeks and led by a Malawian counselor. The group leader compiled transcripts of each session and these transcripts were qualitatively analyzed for thematic information.

RESULTS

Thematic analysis demonstrated a variety of psychological issues discussed by both survivors and caregivers. Caregivers discussed themes of guilt and self-blame for their children's injuries, worries about emotional distance now created between caregiver and survivor, fears that hospital admission meant likely patient death and concerns about their child's future and burn associated stigma. Burn survivors discussed frustration with long hospitalization courses, hope created through interactions with hospital staff, the association between mental and physical health, rumination about their injuries and how this would affect their future, decreased self-value, increased focus on their own mortality and family interpersonal difficulties.

CONCLUSIONS

The establishment of a support group in our burn unit provided a venue for burn survivors and their families to discuss subjective experiences, as well as the dissemination of various coping techniques. Burn survivors and their caregivers in Malawi would benefit from the establishment of similar groups in the future to help address the psychological sequelae of burns.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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