Nutrition education programs for burn survivors: A scoping review

Background: Despite the importance of nutrition education for burn survivors, only limited work has been done to ascertain what is known about these education programs. Aim: To scope the existing literature to ascertain what is known about the nature and outcomes associated with nutrition education programs for burn survivors, their families and caregivers. Methods: Arksey and O'Malley scoping review approach were utilized with searches across peer-reviewed databases and gray literature sources. Results: Six studies were retained. Five studies focused on burn survivors and one focused on healthcare professionals. One study reported improved knowledge regarding postburn nutritional support following the implementation of the nutrition counseling program. Three studies reported on the inclusion of a nutrition education component in comprehensive postdischarge rehabilitation programs albeit no nutrition-specific outcomes were reported. Conclusion: The review affirms the limited literature, highlighting a need for more work to implement and evaluate outcomes of nutrition education programs for burn survivors.

Epidemiology and Outcomes of Cooking- and Cookstove-Related Burn Injuries: A World Health Organization Global Burn Registry Report

Cooking- and cookstove-related burns (CSBs) comprise a large proportion of burn injuries globally, but there are limited data on cooking behavior patterns to inform prevention and advocacy. Therefore, we aimed to describe the epidemiology, risk factors, and outcomes of these injuries and highlight the potential of the World Health Organization (WHO) Global Burn Registry (GBR). Patients with cooking-related burns were identified in the WHO GBR. Patient demographics, cooking arrangement, injury characteristics, and outcomes were described and compared. Bivariate regression was performed to identify risk factors associated with CSBs. Analysis demonstrated that 25% of patients in the GBR sustained cooking-related burns (n = 1723). The cooking environment and cooking fuels used varied significantly by country income level ([electricity use: LIC 1.6 vs MIC 5.9 vs HIC 49.6%; P < .001] [kerosene use: LIC 5.7 vs MIC 10.4 vs HIC 0.0%; P < .001]). Of cooking-related burns, 22% were cookstove-related burns (CSBs; 311 burns). Patients with CSBs were more often female (65% vs 53%; P < .001). CSBs were significantly larger in TBSA size (30%, IQR 15-45 vs 15%, IQR 10-25; P < .001), had higher revised Baux scores (70, IQR 46-95 vs 28, IQR 10-25; P < .001) and more often resulted in death (41 vs 11%; P < .001) than other cooking burns. Patients with CSBs were more likely to be burned by fires (OR 4.74; 95% CI 2.99-7.54) and explosions (OR 2.91, 95% CI 2.03-4.18) than other cooking injuries. Kerosene had the highest odds of CSB compared to other cooking fuels (OR 2.37, 95% CI 1.52-3.69). In conclusion, CSBs specifically have different epidemiology than cooking-related burns. CSBs were more likely caused by structural factors (eg, explosion, fire) than behavioral factors (eg, accidental movements) when compared to other cooking burns. These differences suggest prevention interventions for CSBs may require distinctive efforts than typically deployed for cooking-related injuries, and necessarily involve cookstove design and safety regulations to prevent fires and explosions.

"Managing uncertainty": Experiences of family members of burn patients from injury occurrence to the end-of-life period

BACKGROUND

Although mortality rates associated with burns have decreased, there is still a significant number of persons who may not survive severe forms of the injury and thus, undergo comfort/end of life care. The experiences of family members of persons whose injuries are deemed unsurvivable remain minimally explored and there is a general lack of practice guidelines and recommendations to support them at the end-of-life period.

AIM

To explore the experiences of family members whose relatives died in the burn unit to inform the development of practice recommendations.

METHODS

Qualitative description was employed for this study. Convenience sampling was used to recruit 23 family members of injured persons who died in the burn unit. Face to face semi-structured interviews were conducted and followed up with telephone interviews. The interviews were audio-recorded, transcribed verbatim and thematic analysis performed inductively.

RESULTS

Three themes emerged: reactions following injury occurrence, navigating through the experience, and managing uncertainties about survival. The sudden nature of the injury led to feelings of self-blame, guilt, helplessness, and grief and these escalated at the end of life. As the family members journeyed through their uncertainties regarding the outcomes of care, they had a feeling of being a part of the patient's suffering. Family members received little professional support in coming to terms with their loss in the post-bereavement period.

CONCLUSIONS

Family members experience distress following the occurrence of burns and at the endof-life period. Practice recommendations should focus on communication, bereavement, and post-bereavement support.

"Hanging in a balance": A qualitative study exploring clinicians' experiences of providing care at the end of life in the burn unit

BACKGROUND

Although the culture in burns/critical care units is gradually evolving to support the delivery of palliative/end of life care, how clinicians experience the end of life phase in the burn unit remains minimally explored with a general lack of guidelines to support them.

AIM

To explore the end of life care experiences of burn care staff and ascertain how their experiences can facilitate the development of clinical guidelines.

DESIGN

Interpretive-descriptive qualitative approach with a sequential two phased multiple data collection strategies was employed (face to face semi-structured in-depth interviews and follow-up consultative meeting). Thematic analysis was used to analyze the data.

SETTING/PARTICIPANTS

The study was undertaken in a large teaching hospital in Ghana. Twenty burn care staff who had a minimum of 6 months working experience completed the interviews and 22 practitioners participated in the consultative meeting.

RESULTS

Experiences of burn care staff are complex with four themes emerging: (1) evaluating injury severity and prognostication, (2) nature of existing system of care, (3) perceived patient needs, and (4) considerations for palliative care in burns. Guidelines in this regard should focus on facilitating communication between the patient and family and staff, holistic symptom management at the end of life, and post-bereavement support for family members and burn care practitioners.

CONCLUSIONS

The end of life period in the burn unit is poorly defined coupled with prognostic uncertainty. Collaborative model of practice and further training are required to support the integration of palliative care in the burn unit.

Developing a Breast Reconstruction Program in a Resource-Constrained Ghanaian Teaching Hospital: Needs Assessment and Implementation

ABSTRACT

As the detection of breast cancer in Ghana improves, the incidence of mastectomy has increased and the outcomes have improved. As a secondary result, the need for breast reconstruction is increasing. The cultural hesitation to undergo a mastectomy and live without a breast can be decreased by making breast reconstruction available, cost-effective, and acceptable. Cultural, economic, and technical factors were considered in choosing the best method of breast reconstruction. Discussions, lectures, and cadaver dissections investigated the various reconstructive options. Operative cases were performed using a latissimus musculocutaneous flap, a lower abdominal transverse rectus abdominis myocutaneous (TRAM) flap, and a midabdominal TRAM flap. The midabdominal TRAM was found to be the best choice at Komfo Anokye Teaching Hospital. It is a reliable, robust, well-perfused, single-stage flap that produced excellent patient satisfaction.

Lessons Learned From Implementation and Management of Skin Allograft Banking Programs in Low- and Middle-Income Countries: A Systematic Review

Wound excision and temporary coverage with a biologic dressing can improve survival for patients with large burns. Healthcare systems in low- and middle-income countries (LMICs) rarely have access to allografts, which may contribute to the limited survival of patients with large burns in these settings. Therefore, we aimed to describe the lessons learned from the implementation and maintenance of tissue banks in LMICs to guide system planning and organization. PubMed, MEDLINE, CINAHL, and World Health Organization Catalog were systematically searched with database-specific language to represent a priori terms (eg, skin, allograft, and tissue bank) and all LMICs as defined by the World Bank. Data regarding tissue banking programs were extracted and described in a narrative synthesis. The search returned 3346 records, and 33 reports from 17 countries were analyzed. Commonly reported barriers to ideal or planned implementation included high capital costs and operational costs per graft, insufficient training opportunities, opt-in donation schemes, and sociocultural stigma around donation and transplantation. Many lessons were learned from the implementation and management of tissue banks around the world. The availability of skin allografts can be improved through strategic investments in governance and regulatory structures, international cooperation initiatives, training programs, standardized protocols, and inclusive public awareness campaigns. Furthermore, capacity-building efforts that involve key stakeholders may increase rates of pledges, donations, and transplantations. Some issues were ubiquitously reported and could be addressed by current and future tissue banking programs to ensure allograft availability for patients living in countries of all income levels.

The Role of Palliative Care in Burns: A Scoping Review

CONTEXT

Patients with severe burns may face distressing symptoms with a high risk of mortality as a result of their injury. The role of palliative care in burns management remains unclear.

OBJECTIVE

To appraise the literature on the role of palliative care in burns management.

METHODS

We used scoping review with searches in 12 databases from their inception to August 2019. The citation retrieval and retention are reported in a PRISMA statement.

FINDINGS

39 papers comprising of 30 primary studies (26 from high-income and four from middle-income countries), four reviews, two editorials, two guidelines, and one expert board review document were retained in the review. Palliative care is used synonymously with comfort and end-of-life care in burns literature. Comfort care is mostly initiated when active treatment is withheld (early deaths) or withdrawn (late deaths), limiting its overall benefits to burn patients, their families, and health care professionals. Futility decisions are usually complex and challenging, particularly for patients in the late death category, and it is unclear if these decisions result in timely commencement of comfort care measures. Three comfort care pathways were identified, but it remained unclear how these pathways evaluated "good death" or supported the family which creates the need for the development of other evidence-based guidelines.

CONCLUSION

Palliative care is applicable in burns management, but its current role is mostly confined to the end-of-life period, suggesting that it is not been fully integrated in the management process. Evidence-based guidelines are needed to support the integration and delivery of palliative care in the burn patient population.

Assessment of mortality prediction models in a Ghanaian burn population

PURPOSE

Over 40 new or modified outcome prediction models have been developed for severe burns; with age, total burned surface area (TBSA) and inhalation area as major determinants of mortality. The objective of this study was to assess their applicability in a developing country.

PROCEDURES

Data were collected retrospectively of a consecutive series of 261 patients (2009-2011) admitted to a Burns Intensive Care. Five outcome prediction models based on admission criteria were evaluated: Bull grid, Abbreviated Burn Severity Index--ABSI, Ryan-model, Belgian Outcome in Burn Injury--BOBI and revised Baux. Discriminative power and goodness-of-fit were assessed by receiver operating characteristic analyses (area under the curve--AUC) and Hosmer-Lemeshow tests.

FINDINGS

Median age was 10.5 years (IQR: 2.5-27 years), median TBSA 21% (IQR: 11-34%); 55.2% were male, 28 patients died (10.7%). Only 2 patients were intubated (0.8%). The AUC were between 77 and 86%. The ABSI model showed the best calibration (28.7 expected deaths). Ryan, BOBI and rBaux significantly underestimated mortality, whereas Bull showed an overestimation.

CONCLUSION

This study on a young group of burn patients showed moderate to good discriminative power using all five prediction models. The expected number of deaths tended to be underestimated in the three most recent prediction models.

Gastrointestinal stromal tumour presenting acutely as gastroduodenal intussusception

INTRODUCTION

Gastrointestinal stromal tumours (GISTs) are uncommon tumours of the gastrointestinal (GI) tract. We report a case of a gastric GIST that presented acutely as a gastroduodenal intussusception.

CASE PRESENTATION

A 59-year-old woman presented with a week's history of vomiting anything she swallowed. Physical examination revealed a mildly tender abdomen without guarding or rebound tenderness. An epigastric mass was, however, palpated. Abdominal ultrasonography suggested an intussusception. At laparotomy, a tumour on the anterior wall of the stomach causing intussusception of the stomach into the duodenum was found. After reducing the intussusception, a wedge resection of the tumour was performed, which proved to be a GIST.

DISCUSSION

GISTs represent a rare group of neoplasms of the GI tract. Gastric intussusception is a rarely documented condition. Symptoms range from intermittent epigastric pain to sudden onsets of severe pain with vomiting and shock. Pre-operative diagnosis can be difficult and diagnosis cannot be confirmed until surgery. The treatment of choice for localised gastric GIST is surgical resection.

CONCLUSION

Although gastroduodenal intussusception, particularly secondary to a GIST, is uncommon, clinicians need to have a high index of suspicion in acutely vomiting patients, especially if they have experienced similar symptoms intermittently in the immediate past.