A clinician's guide to the treatment of foot burns occurring in diabetic patients

IntroductionDiabetes mellitus affects 25.8 million Americans and is predicted to almost double by 2050. The presence of diabetes complicates hospital courses because of the microvascular complications associated with disease progression. Patients with diabetes represent 18.3% of annual burn admissions to our unit and 27% have burns to the feet. The purpose of this project was to develop an evidence-based guideline for care of the patient with diabetes and foot burnsMethodsA multidisciplinary group was charged with developing an evidence-based guideline for the treatment of foot burns in patients with diabetes. Evidence was evaluated in the areas of diabetes, burn care, hyperbaric medicine, care of diabetic foot wounds and physical therapy. After guideline development and approval, key aspects were incorporated into order sets.ResultsKey aspects of this guideline are the ability to identify patients with undiagnosed diabetes, assess diabetic control, optimize glycemic and metabolic control, optimize burn wound management, treat microvascular disease, and provide education and a discharge plan. Evaluated outcomes are glycemic control, length of stay, complication rates, amputation rates, infection rates and the use of hyperbaric oxygen.ConclusionsBest outcomes for this high risk population will be attainable with an evidence based guideline.     

Impact of diabetes on clinical outcome in severely burned patients

IntroductionAccording to the International Diabetes Federation, approximately 425 million people worldwide suffer from diabetes mellitus, a figure that will double in the next 20 years. Data on the ratio of treated diabetics in burn intensive care units remain scarce and the effects on the mortality rate are poorly defined.MethodsOur retrospective, single-centre study aimed to evaluate differences in the risk factors due to diabetes mellitus, the clinical outcome and the patient population of diabetic patients after severe burn injuries over a time period of 21 years.ResultsDespite increasing numbers of diabetic patients, the ratio of burn patients suffering from diabetes remained stable during the study period. The risk factors for mortality were higher age (OR 1.03, 95% confidence interval (CI), 1.02–1.04, p < 0.0001), female sex (OR 1.56, 95% CI, 1.06–2.29, p = 0.025), higher % total body surface area (TBSA) (OR 3.88, 95% CI, 2.81–5.46, p < 0.0001), full thickness burns (OR 8.58, 95% CI, 3.84 – 23.60, p < 0.0001) and the presence of inhalation injuries (OR 4.68, 95% CI, 3.15–7.02, p < 0.0001) Patients with diabetes had a smaller extent of burned areas with a median TBSA of 30% (quartiles: 22–50%, p = 0.036) compared to non-diabetic patients (35% (25–55%)) but had a similar length of stay with a median of 29 (quartiles: 13–44) days vs. 23 (10–48) days. Outcome analysis showed an overall mortality of 35.6%. Diabetes was not associated with higher mortality rate after burn injury in a univariate model (OR 1.80, 95% CI 0.92–3.51). After correction for %TBSA, the effect of diabetes on mortality was significant (OR 2.80, 95% CI, 1.33–5.90).ConclusionOur data indicate higher mortality rates (50–100%) of diabetic patients with TBSA greater than 40% in severely burned patients compared to non-diabetic patients without a significant outcome due to the low number of cases in the subgroup analyses.     

Patients en hémodialyse : l’incidence de cancer est-elle différente entre les diabétiques de type 2 comparés aux non-diabétiques ? Une étude du registre REIN

Background and objectivesIn France, diabetes mellitus is now the second cause of end stage renal disease. In a large previous French national study, we observed that dialyzed diabetics have a significant lower risk of death by cancer. This first study was focused on cancer death but did not investigate cancer incidence. In this context, the aim of this second study was to compare the incidence of cancer in diabetic dialyzed patients compared to non-diabetic dialyzed patients in a French region.MethodsThis epidemiologic multicentric study included 588 diabetic and non-diabetic patients starting hemodialysis between 2002 and 2007 in Bretagne. Data were issued from REIN registry and cancer incidence were individually collected from medical records. Diabetics and non-diabetics were matched one by one on age, sex and year of dialysis initiation.ResultsDuring the follow-up, we observed 28 cancers (9.4%) in diabetic patients and 26 cancers (8.9%) in non-diabetics patients. The cumulative incidence to develop a cancer 2 years after the dialysis start was approximately 6% in both diabetics and non-diabetics patients. In univariate Fine and Gray analysis, BMI, hemoglobin, statin use had P-value < 0.2. However, in the adjusted model, these variables were not significantly associated with cancer incidence.ConclusionThis study lead on a little number of dialyzed patients did not show any significant difference on cancer incidence between diabetic and non-diabetic patients after hemodialysis start.     

Clinical outcomes of isolated lower extremity or foot burns in diabetic versus non-diabetic patients: A 10-year retrospective analysis

Introduction

The incidence of diabetes mellitus (DM) in the United States is expected to increase from 8 per 1000 in 2008 to 15 per 1000 by 2050 [20]. As a result, DM patients will constitute a large proportion of Burn Center admissions, with burns typically due to contact burn or scalding. Peripheral vascular disease (PVD) and peripheral neuropathy (PN) are far more common in DM patients, particularly in those with poorly controlled disease, and are often associated with worse outcomes than non-diabetic (nDM) burn patients. This study sought to analyze whether the outcome of isolated leg and foot burns among DM and nDM individuals differed significantly.

Materials and methods

Retrospective data on 207 consecutive patients (>18 years old) admitted to a Burn Center with isolated leg or foot burns between 1999 and 2009 was collected and analyzed for this study. Age, gender, ethnicity, total body surface area (TBSA), degree of burn, etiology, hospital and burn intensive care unit (ICU), length of stay (LOS), and status at discharge were reviewed. Patients were grouped as diabetic (DM) or non-diabetic (nDM). Differences were analyzed using either the Student's t-test or Chi-square.

Results

43 DM and 164 nDM patients with isolated lower extremity or foot burns were treated during the study period (1999–2009). The mean age of DM and nDM patients was 54.6 and 43.7 years, respectively (p < 0.001). The most common burn etiology was scalding, flame, or contact burn. Percentage of total body surface area (TBSA) burn in DM patients averaged ± standard deviation 1.8 ± 1.3% compared to 1.8 ± 1.6% in nDM (p < 0.9). Among DM patients, 86% (N = 37) of patients suffered third degree burns and 14% (N = 6) of patients had second degree burns compared to 76% (N = 125) of patients and 24% (N = 39) of patients among nDM patients, respectively (p < 0.16). The DM group had significantly higher burn ICU admission rates, 16.3% of patients versus 8.5% of patients (p < 0.001), total length of hospital stay (mean ± standard deviation), 14.1 ± 10 versus 9.8 ± 9.3 days (p < 0.01) and renal failure, 4.7% of patients versus 0.6% of patients (p < 0.05) compared to the nDM group. 93% of DM patients were discharged to home without further medical attention while 4.7% of patients underwent further treatment. In comparison, 85.4% of the nDM patients were discharged home with no further treatment while 8.5% of patients received home care (p < 0.01).

Conclusion

DM patients who suffer isolated burns to the feet or lower extremities have poorer clinical outcomes and more complicated and protracted hospital courses when compared to nDM patients with similar burns. Although diabetics in the current study did not experience larger or more severe burns than nDM patients, they were nearly twice as likely to be admitted to the ICU, spent an average of four days longer in the hospital, and had a higher likelihood of developing renal failure compared to nDM patients.     

The effect of burn mechanism on pediatric mortality in Malawi: A propensity weighted analysis

IntroductionThe burden of global trauma disproportionately affects low- and middle-income countries, with a high incidence in children. Thermal injury represents one of the most severe forms of trauma and is associated with remarkable morbidity and mortality. The predictors of burn mortality have been well described (age, % total body surface area burn [TBSA], and presence of inhalation injury). However, the contribution of the burn mechanism as a predictor of burn mortality is not well delineated.MethodsThis is a retrospective analysis of prospectively collected data, utilizing the Kamuzu Central Hospital (KCH) Burn Surveillance Registry from May 2011 to August 2019. Pediatric patients (≤12 years) with flame and scald burns were included in the study. Basic demographic variables including sex, age, time to presentation, %TBSA, surgical intervention, burn mechanism, and in-hospital mortality outcome was collected. Bivariate analysis comparing demographic, burn characteristics, surgical intervention, and patient outcomes were performed. Standardized estimates were adjusted using inverse-probability of treatment weights (IPTW) to account for confounding. Following weighting, logistic regression modeling was performed to determine the odds of in-hospital mortality based on burn mechanism.ResultsDuring the study period, 2364 patients presented to KCH for burns and included in the database with 1794 (75.9%) pediatric patients. Of these, 488 (27.6%) and 1280 (72.4%) were injured by flame and scald burns, respectively. Males were 47.2% (n = 230) and 59.2% (n = 755) of the flame and scald burn cohorts, respectively (p < 0.001.) Patients presenting with flame burns compared to scald burns were older (4. 7 ± 3.1 vs. 2.7 ± 2.3 years, p < 0.001) with greater %TBSA burns (17.8 [IQR 10–28] vs 12 [IQR 7–20], p < 0.001). Surgery was performed for 42.2% (n = 206) and 19.9% (n = 140) of the flame and scald burn cohorts, respectively (p < 0.001.) Flame burns had a 2.6x greater odds of in-hospital mortality compared to scald burns (p < 0.001) after controlling for sex, %TBSA, age, time to presentation, and surgical status.ConclusionIn this propensity-weighted analysis, we show that burn mechanism, specifically flame burns, resulted in a nearly 3-fold increase in odds of in-hospital mortality compared to scald burns. Our results emphasize flame and scald burns have major differences in the inflammatory response, metabolic profile over time, and outcomes. We may further utilize these differences to develop specialized treatments for each burn mechanism to potentially prevent metabolic dysfunction and improve clinical outcomes.     

Effect of comorbidities on clinical outcome of patients with burn injury — An analysis of the German Burn Registry

BackgroundSevere burn injuries are associated with high morbidity and mortality. Well-implemented scoring systems for patients with major burns exist in the literature. A major disadvantage of these scores is the partial non-consideration of patient-related comorbidities. Published data on this matter is limited to small study cohorts and/or single center studies. Further, the effect of comorbidities on clinical outcome of patients with severe burn injuries has not yet been examined nationwide in a large cohort in Germany. Hence, the aim of this study was to examine the influence of comorbidities on clinical outcome of these patients based on data from the national registry.MethodsAnonymized data from a total of 3455 patients with documented burns of 1% or more Total Burn Surface Area (TBSA) and over 16 years of age included in the German Burn Registry between 2017 and 2018 were analyzed retrospectively. Data included burn extent, body weight, age, burn depth, inhalation injury, comorbidities, mortality, number of operations and length of hospital stay (LOS).ResultsIn the logistic regression analysis age (OR 1.07 [1.06–1.09], p < 0.001), TBSA (OR 1.09 [1.08–1.11], p < 0.001), IHT (OR 2.15 [1.44–3.20], p < 0001), third degree burn (OR 2.08 [1.39–3.11], p < 0.001), Chronic Obstructive Pulmonary Disease (COPD) (OR 2.45 [1.38–4.35], p = 0.002) and renal insufficiency (OR 2.02 [1.13–3.59], p = 0.017) influenced mortality significantly. If a patient had more than one comorbidity, mortality was higher and in-hospital length of stay (LOS) longer. Renal insufficiency was significantly (p < 0.001) associated with the most prolonged LOS by 11.44 days. TBSA (p < 0.001), Abbreviated Burn Severity Index (ABSI) > 3 (p < 0.001) and IHT (p = 0.001) correlated with the amount of required surgeries and significantly predicted the need for intubation. Patients with arrhythmia significantly required more surgeries (p = 0.041), whereas patients with COPD required significantly less surgical interventions (p = 0.013).ConclusionPreexisting comorbidities have a significant impact on the clinical outcome of patients with severe burn injuries. Further investigation is warranted in order to supplement existing prognostic scores with new mortality-associated parameters.     

Increased risk of blood transfusion in patients with diabetes mellitus sustaining non-major burn injury

BackgroundDue to the increased mortality and morbidity associated with blood transfusion, identifying modifiable predictors of transfusion are vital to prevent or minimise blood use. We hypothesised that burn patients with diabetes mellitus were more likely to be prescribed a transfusion. These patients tend to have increased age, number of comorbidities, infection risk and need for surgery which are all factors reported previously to be associated with blood use.ObjectiveTo determine whether patients with diabetes mellitus who have sustained a burn ≤20% total body surface area (TBSA) are at higher risk of receiving red blood cell transfusion compared to those without diabetes mellitus.MethodThis was a retrospective cohort study including patients admitted to the major Burns Unit in Western Australia for management of a burn injury. Only the first hospital admission between May 2008 to February 2017 were included.ResultsAmong 2101 patients with burn injuries ≤20% TBSA, 48 (2.3%) received packed red blood cells and 169 (8.0%) had diabetes. There were 13 (7.7%) diabetic patients that were transfused versus 35 (1.8%) non-diabetic patients. Patients with diabetes were 5.2 (p = 0.034) times more likely to receive packed red blood cells after adjusting for percentage TBSA, haemoglobin at admission or prior to transfusion, number of surgeries, total comorbid burden and incidence of infection. As percentage TBSA increases, the probability of packed red blood cell transfusion increases at a higher rate in DM patients.ConclusionsThis study showed that diabetic patients with burn injuries ≤20% TBSA have a higher probability of receiving packed red blood cell transfusion compared to patients without diabetes. This effect was compounded in burns with higher percentage TBSA.     

Effective reduction in stress induced postoperative hyperglycemia in bariatric surgery by better carb loading

BackgroundPreoperative carbohydrate loading is a recommended component of enhanced recovery protocols (ERP’s), however the impact on postoperative stress-induced insulin resistance remains poorly studied in both diabetics and non-diabetics.MethodsUsing our ERP, a preoperative grape juice group (Grape) was compared to the use of 25 g maltodextrin/3 g citrulline (G.E.D.™, SOF Health, LLC) for carbohydrate loading.ResultsThe population included 171 patients (Grape n = 96; GED n = 75). Glycemic variability was significantly worse for the Grape group on POD 0 in both non-diabetic (70% vs 41%; p < 0.05) and diabetic patients (66% vs 34%; p < 0.05). Significantly more Grape patients required postoperative insulin regardless of diabetic status.ConclusionFollowing bariatric surgery, the impact of stress induced hyperglycemia is primarily on POD 0 in non-diabetics whereas the effect extends into POD 1 for diabetics. Preoperative loading with G.E.D.™ versus grape juice is associated with a significantly lower rate of glycemic variation and postoperative insulin requirement, demonstrating that drink composition and treatment process reduces the severity of postoperative stress induced hyperglycemia in bariatric surgery patients.     

The impact of youth-onset type 2 diabetes on postoperative wound healing complications

Youth-onset type 2 diabetes mellitus is associated with a more rapid decline in β cells, and earlier onset of medical complications compared to adult-onset diabetes. However, its impact on surgical wounds remains less clear. Therefore, this study aimed to determine whether youth-onset diabetes is a risk factor for wound healing complications in the 30-day postoperative period. To do so, the National Surgical Quality Improvement Program Database years 2012–2019 was analysed. Patients aged 18–24 with non-insulin-dependent diabetes were included. Outcomes assessed included wound infections, wound dehiscence, readmissions, and reoperation. Univariate analysis identified differences between the diabetic and non-diabetic cohorts after which, multivariate logistic regression was employed to control for potential confounding. Analysis included 1589 diabetic and 196,902 non-diabetic patients ages 18–24. The diabetic cohort exhibited a higher proportion of female (83.8% vs. 55.2%, p < 0.001), non-white (22.7% vs. 19.5%, p = 0.001), and Hispanic patients (16.2% vs. 13.6%, p = 0.002). Diabetic patients were less likely to have dirty or contaminated wounds (16.2% vs. 25.2%, p < 0.001); however had increased rates of superficial surgical site infections (SSSIs; 2.0% vs. 0.8%, p < 0.001) and readmission (4.0% vs. 3.0%, p = 0.026). After regression, diabetes remained a significant positive predictor of SSSI (odds ratio: 1.546, p = 0.022); however, it no longer significantly predicted 30-day readmission. Overall, this analysis of a large multicentre surgical outcomes database found that when compared to non-diabetics, youth-onset diabetic patients exhibited a higher proportion of SSSIs in the 30-day postoperative period. These infections were found, despite the diabetic cohort exhibiting lower rates of wound contamination. After controlling for confounding variables, youth-onset diabetes remained a significant predictor of SSSI. Clinically, prevention and treatment of diabetes along with judicious wound care is recommended.     

Coffee break – Epidemiologic analysis,traditions & holidays that increase burn risk of pediatric patients

BackgroundBurns are estimated to cause up to 1% of admissions to emergency department in low- and middle-income countries, and up to 220 admissions per 100 K people in high income countries. Knowing the special features in every population could help formulate prevention strategies tailored for the specific group targeted and thus help decrease the incidence of burns in the general population.Patients and MethodsWe examined all patients files admitted to the Rappaport hospital within Rambam Medical Center between the years 2012–2016.ResultsMale admissions accounted for 57% (18.1 per 100 K life years) of all admissions. Scald was the most prominent cause of burn in all the cohort subgroups, with 65% of all burns. The specific cause of scald varied in the subgroups. Burns usually happened during weekend (p < 0.001). Transition seasons, i.e. autumn and spring, were the most dangerous for our cohort (p < 0.001).ConclusionsPediatric burn patterns were found correlate to population, timing, and customs. Mapping the hazardous rituals that may cause burns in different populations, is the first step towards prevention.     

Pediatric instant noodle burns: A ten-year single center retrospective study

IntroductionChildren are particularly vulnerable to scald injuries, and hot beverages/foods are often implicated in this subset of pediatric burns. Burns from instant noodles are common and thus an attractive target for burn prevention. The purpose of this study is to characterize the frequency, demographics, outcomes, and circumstances of pediatric instant noodle burns to guide future educational and prevention efforts.MethodsThis is a retrospective review of all pediatric patients (<18 years) admitted to the University of Chicago Burn Center with a diagnosis of scald injury between 2010 and 2020. Burns caused by instant noodles were identified and compared to all other scald burns over this period.ResultsAmong 790 pediatric scald burns, 245 (31.0 %) were attributed to instant noodles. Compared to other scalds, patients with instant noodle burns were older (5.4 vs. 3.8 years, p < 0.001), equally likely to be male (51 % vs. 54 %, p = 0.488), and more likely to be Black/African American (90.6 % vs. 75.2 %, p < 0.001). Patients with instant noodle burns lived in zip codes with a lower average childhood opportunity index score (9.9 vs. 14.6, p < 0.001). In terms of circumstances, children with instant noodle burns were more likely to be unsupervised at the time of injury (37 % vs 21 %, p < 0.001). Instant noodle burns were smaller (3.6 % total body surface area (TBSA) vs. 5.8 % TBSA, p < 0.001) and less likely to require operative intervention (29 % vs. 41 %, p < 0.001). Instant noodle burns had a shorter length of stay (4.2 days vs. 6.4 days, p < 0.001), but similar adjusted length of stay (1.7 days/%TBSA vs. 1.5 days/%TBSA, p = 0.18) and experienced similar complication rates (10 % vs. 15 %, p = 0.06).ConclusionInstant noodle burns comprised nearly one-third of all pediatric scald burn admissions at our institution, a higher proportion than previously reported. While less severe than other scald burns in this series, instant noodles injuries still demonstrated a need for hospitalization and operative intervention. Instant noodle burns disproportionately affected Black/African American patients, as well as from neighborhoods with lower socioeconomic status. These findings suggest that focused burn prevention efforts may be successful at reducing the incidence of these common, but serious injuries.     

Graft patency and clinical outcome of femorodistal arterial reconstruction in diabetic and non-diabetic patients: results of a multicentre comparative analysis.

OBJECTIVE: in diabetic patients with critical limb ischaemia (CLI) an inferior success rate following infrainguinal bypass surgery is quite often suggested. The aim of this retrospective analysis was, therefore, to evaluate the graft patency and, particularly, the clinical outcome at 1 year in diabetic compared with non-diabetic patients. MATERIAL AND METHODS: two hundred and eleven patients (diabetics 94; non-diabetics 117) with femorodistal reconstruction for CLI were studied. Groups were comparable with regard to the Fontaine classification, the distribution of vascular risk factors, graft material, distal anastomosis site, and the angiographic runoff grading. RESULTS: diabetes did not adversely affect graft function. For diabetics and non-diabetics primary cumulative patency rate at 1 year was found to be 66 and 56%, respectively (p=0.10) and a virtually identical limb salvage rate of 85 and 83% was achieved (p=0.76). With regard to healing of ischaemic foot ulcers a trend against diabetics was noted with a healing rate of 81% compared to 96% in non-diabetics at 1 year (p=0.067); gangrenous foot lesions could be equally remedied in 94% and in 87% among patients with and without diabetes (p=0.44). The survival rate of diabetics, however, was significantly lower with 78% at 1 year compared with 95% in non-diabetic patients (p=0.0004). CONCLUSIONS: our preliminary results support the view that infrainguinal bypass grafting can be safely done even in diabetics. Despite increased mortality in this group, liberal indication for reconstructive vascular surgery seems to be justified by favourable patency rates and clinical outcome in selected patients.     

Clinical outcome and determinants of amputation in a large cohort of Iranian patients with diabetic foot ulcers

ObjectiveDetermining the predictive factors of diabetes foot ulcer (DFU) development and lower extremity amputations (LEA) in patients with diabetes mellitus (DM) is of great importance to compose risk stratification models. The aim of this study is to investigate the outcome and predictors of LEA in patients with DFU in large sample of Iranian patients.MethodsThis prospective cohort study was conducted during a 2-year period from 2014 to 2016, in Shiraz, southern Iran. All the patients with type 1 and 2 DM and DFU were included in the cohort and were followed for 2 years at least. They were visited in the clinic on a monthly basis and development of new DFU and LEA were recorded. The two-year free-DFU survival and predictors of the DFU development and LEA were recorded. Multivariate regression models were used to determine the factors.ResultsA total number of 432 patients with mean age of 56.8 ± 13.3 years were included. The two-year DFU-free survival rate was 0.826. The two-year DFU-free survival was associated with male gender (p = 0.005), foot deformity (p = 0.002), history of prior DFU (p < 0.001), cigarette smoking (p = 0.032), nephropathy (p = 0.005), retinopathy (p = 0.007), ischemic heart disease (p = 0.043), and neuropathy (p < 0.001).ConclusionDevelopment of new DFU is associated with higher age, longer duration of disease, and type I diabetes. LEA was associated with increased white blood cell (WBC), Creatinine and ulcer history for major amputation and ulcer history, fasting blood sugar (FBS), infection, revascularization history, and foot deformity, for minor amputation.     

Comparative analysis of functional and aesthetic outcomes of retroauricular full thickness versus plantar glabrous split thickness skin grafts in pediatric palmar hand burns

BackgroundOptimal management of palmar hand burns in children is controversial. We aimed to compare function and aesthetics of retroauricular full thickness skin grafts (FTSG) to plantar glabrous split thickness skin grafts (STSG).Methods32 palmar grafts in paediatric burn patients were analysed: 19 retroauricular FTSG (group 1) and 13 thick plantar glabrous STSG (group 2). The latter were harvested at a thickness of 0.5 mm. The resulting plantar donor defects were covered with a STSG from the scalp, a sequential surgical technique we termed the “Zurich move”. Clinical examination, Cutometer and Colorimeter assessment and validated patient and observer questionnaires were used. Donor site complications and subjective complaints were recorded.ResultsColorimeter results were superior in group 2 with an erythema score of 5.73 ± 2.64 (group 1) versus 2.33 ± 1.97 (group 2, p < 0.001) and a pigmentation score of 9.82 ± 5.42 (group 1) and 1.89 ± 1.92 (group 2, p < 0.001). Observers` scar evaluation using VSS and POSAS showed significantly superior results in group 2 for almost all items. Conversely, group 1 grafts were less stiff with mean normalized tissue extension R0 of 0.80 ± 0.21 versus 0.57 ± 0.24 in group 2 grafts (p < 0.05). In both groups donor sites complications were rare.ConclusionPlantar glabrous STSG showed superior functional and aesthetic results when compared to FTSG in pediatric palmar hand burns. In addition, the “Zurich Move” is safe and provides uncomplicated donor site healing on the scalp and the foot allowing rapid restoration of full function.     

Potential efficacy of sensorimotor exercise program on pain,proprioception, mobility,and quality of life in diabetic patients with foot burns: A 12-week randomized control study

BackgroundBoth diabetes mellitus (DM) and burn injuries lead to physical and psychological impairments. Foot burns are still a challenging health condition because of its important sensory role. No previous studies have assessed the physical therapy intervention on diabetic patients with foot burns. Therefore, this study aimed to assess the potential efficacy of sensorimotor exercise on pain, proprioception, mobility, balance, and quality of life in diabetic patients with foot burns.MethodsBetween July 2019 and February 2020, thirty-three diabetic patients with foot burns, aged 32 to 46 yrs, were enrolled in this randomized control study, and randomized consecutively into two groups, study group (n = 16) and control group (n = 17). The study group underwent a sensorimotor exercise program thrice a week for 12 consecutive weeks, however the control group did not undergo the exercise intervention. Both groups were instructed to conduct home exercises. Visual analogue scale (VAS), proprioceptive responses, time-up and go (TUG) values, and short form-36 (SF-36) have been assessed prior and subsequent to the study intervention.ResultsNo significant differences were observed between groups regarding baseline data (p ? 0.05). Subsequent to 12 wk intervention, the study group showed significant improvements in outcome measures (proprioceptive responses, p ? 0.05, VAS, p ? 0.001, TUG, p = 0.003, and SF-36, p ? 0.001) and the control group exhibited significant changes in VAS and SF-36 (p = 0.004, p = 0.043 respectively) however, no significant changes were found in proprioceptive responses and TUG values (p ? 0.05). Between groups, the post-intervention comparison demonstrated statistical differences with tending toward the study group (proprioceptive responses, p ? 0.05, VAS, p ? 0.001, TUG, p = 0.013, and SF-36, p = 0.046).ConclusionsSensorimotor exercise training may improve, pain, proprioceptive responses, mobility, balance, and quality of life in diabetic patients with foot burns. Physiotherapists and rehabilitation providers should include the sensorimotor exercise in their protocols in the treatment of diabetic patients with foot burns.     

Analgesia protocols for burns dressings: Challenges with implementation

BackgroundThe aim of this study is to compare doctors’ knowledge regarding analgesia in paediatric burns patients in a setting where analgesia protocols are provided but not reinforced to a setting where the same protocols are used but with constant re-enforcement from burns surgeons.MethodsWe reviewed questionnaires completed anonymously by doctors managing burns children in the Pietermaritzburg (PMB) Hospital Complex and the referral hospitals.ResultsThe questionnaire was completed by 43 doctors with 53% of the participants working in the referral hospitals. Procedural sedation was given by 98% of doctors. All PMB doctors giving procedural sedation used ketamine compared to 39% in the referral hospitals, which was statistically significant (×2 = 18.237; p < 0.001). Eighty percent of PMB doctors were aware of the correct doses of ketamine and compared to 8% of referral doctors. This was statistically significant (×2 = 21.778; p < 0.001). When assessing the adequacy of analgesia, all of the doctors from PMB used a scoring system or clinical impression. In the referral doctor group, 54% used a scoring system, 38% used the child screaming as an indicator of inadequate analgesia.ConclusionWe have identified a discrepancy in knowledge between staff in an academic burn centre and those in peripheral referral hospitals. This discrepancy translates into differences in quality of burn analgesia which patients receive. Ongoing efforts must be directed towards changing the culture of district institution and strengthening attempts to standardize care across the region.     

Burn patients with history of kidney transplant experience increased incidence of wound infection

ObjectiveTo determine if history of kidney transplant is an independent risk factor for increased incidence of wound infection and other morbidities in burn patients.BackgroundWhile the goal of immunosuppression post-organ transplantation is to prevent graft rejection, it is often associated with significant adverse effects such as increased susceptibility to infection, drug toxicity, and malignancy. Burn injuries lead to a dysregulated hypermetabolic state and a compromised cutaneous barrier, which predisposes to infection and delayed wound healing. We surmise that a history of kidney transplant increases the risk of wound infection in in-hospital burn victims.MethodsA retrospective analysis was performed on 57,948 adults diagnosed in-hospital with a burn injury between 2008–2014, obtained from the Nationwide Inpatient Sample (NIS) by Healthcare Cost and Utilization Project (HCUP).Results103 burn victims (0.2%) with a history of kidney transplant (KTX) were identified. Compared to burn patients without a history of transplant (No-KTX), they were older (54.3 ± 13.8 vs 49.8 ± 18.7; p = 0.001), more likely be insured under Medicare (69.9% vs 31.1%; p < 0.001), and less likely to have Medicaid (5.8% vs 17.2%; p = 0.002). Higher in-hospital mortality index scores were observed in KTX compared to no-KTX with p < 0.001. The incidence rates of complications such as wound infection (33.0 vs 16.3; p < 0.001) and acute renal failure (18.4 vs 7.7; p < 0.001) were significantly higher in the KTX group. After adjusting for confounding factors in multivariable analysis, the incidence of wound infection remained significantly higher. Burn patients with history of KTX were not more likely to be treated at a transplant (TX) center. TX centers were determined to have higher mortality rate, longer length of stay, and higher total hospital charges.ConclusionHistory of kidney transplant is an independent risk factor for increased incidence of wound infection in burn patients.     

Demographics and clinical outcomes of adult burn patients admitted to a single provincial burn centre: A 40-year review

IntroductionThis study evaluated trends in demographics and outcomes of cutaneous burns over a forty-year period at a Canadian burn centre.MethodsRetrospective review was performed of all consecutive adult burn admissions to the Vancouver General Hospital (VGH) between 1976 and 2015. Comparison was made to the 2016 American Burn Association – National Burn Repository.ResultsThere were 4105 admissions during study period. Both overall admissions and admissions per 100,000 BC residents declined (p < 0.0001). Males represented three quarters of admissions. There was a decrease in large burns (p < 0.05). Flame burns were most commonly associated with larger TBSA, ICU stays, and mortality.Mortality decreased from 11.3% to 2.8% (p < 0.05). Factors found to affect mortality included: increased length of stay, age and burn size, male gender, and number of complications. Baux50 and rBaux50 increased, from 102.8 to 116.7 and 112.2 to 125.3 respectively (p < 0.05, respectively).ConclusionsThis study represents the largest report on burn epidemiology in Canada. The incidence of burns has decreased significantly over the last forty years. Mortality has improved over this time frame, as evident by increases in Baux50 and rBaux50 scores. Further data is largely in concurrence with that of the National Burn Repository’s amalgamation of US centres.     

Exploratory analysis of long-term physical and mental health morbidity and mortality: A comparison of individuals with self-inflicted versus non-self-inflicted burn injuries

IntroductionSelf-inflicted burn (SIB) injuries are relatively rare, but patients may experience complex biopsychosocial challenges. This study aimed to compare long-term physical and psychological outcomes for individuals with SIB and non-SIB injuries.MethodsRecords of adult SIB (n = 125) and non-SIB (n = 3604) injuries were collected from U.S. burn centers within the Burn Model System between 1993 and 2018. Assessments were administered at discharge, 6 months, 24 months, 5 years, and 10 years.ResultsSIB patients were more often younger, unmarried, unemployed, male, struggling with pre-morbid psychiatric issues, and injured by fire/flame (all p < 0.001). SIB injury predicted prolonged mechanical ventilation, hospitalization, and rehabilitation (all p < 0.001). After injury, SIB patients had increased anxiety at 24 months (p = 0.0294), increased suicidal ideation at 5 years (p = 0.004), and clinically worse depression at 10 years (p = 0.0695). SIB patients had increased mortality across 24 months compared to non-SIB patients (OR = 4.706, p = 0.010).ConclusionSIB injuries are associated with worse physical and psychological outcomes compared to non-SIB injuries including complicated hospitalizations and chronic problems with anxiety, depression, suicidality, and mortality, even when controlling for common indicators of severity such as burn size. This underscores the importance of multidisciplinary treatment, including mental healthcare, and long-term follow-up for SIB patients. Identified pre-morbid risk factors indicate the need for targeted injury prevention.     

Successful prevention of secondary burn progression using infliximab hydrogel: A murine model

IntroductionBurn injury remains a serious cause of morbidity and mortality worldwide. Severity of burns is determined by the percentage of burned area compared to the body surface area, age of patient, and by the depth of skin and soft tissue involvement; these factors determine management as well as prospective outcomes. The pathophysiology of partial- to full-thickness burn conversion remains poorly understood and is associated with a worse overall prognosis. Recent studies have demonstrated that an altered inflammatory response may play a significant role in this conversion and therefore a reduction in early inflammation is crucial to ultimately decreasing burn severity and morbidity. We hypothesize that the application of a microcapillary gelatin–alginate hydrogel loaded with anti-TNF-α (infliximab) monoclonal antibodies to a partial-thickness burn will reduce inflammation within partially burned skin and prevent further progression to a full-thickness burn.MethodsAssembly of the microfluidic hydrogels is achieved by embedding microfibers within a hydrogel scaffold composed of a gelatin–alginate blend, which is then soaked in a solution containing anti-TNF-α antibodies for drug loading. 12 young (2–4 months) and 12 old (>16 months) mice were given partial thickness burns. The treatment cohort received the anti-TNF-α infused hydrogel with an occlusive dressing and the control cohort only received an occlusive dressing. Mice were euthanized at post-burn day 3 and skin samples were taken. Burn depth was evaluated using Vimentin immunostaining.ResultsAll mice in the treatment cohort demonstrated decreased conversion of burn from partial to full thickness injury (old = p < 0.01, young = p < 0.001) as compared to the control group. Old mice had greater depth of burn than young mice (p < 0.001). There were greater eosinophils in the treatment cohort for both young and old mice, but it did not reach statistical significance.ConclusionThe application of a novel microcapillary gelatin–alginate hydrogel infused with anti-TNF-α antibody to partial thickness burns in mice showed reduction in partial to full thickness burn secondary progression as compared to controls using this murine model; this promising finding might help decrease the high morbidity and mortality associated with burn injuries.