Does Referral Distance Deteriorates the Burn Patients Outcome? Results From an Academic Tertiary Hospital in a Developing Country.

Every year millions of people are burned and many of them are transported to specialized burn centers. One of the most important challenges in the face of burn patients in urban areas is deciding about referring patients to specialized burn centers. In this study, correlation between referral distance and mortality rate is investigated. Our cross-sectional analytic study included admission data of 7248 burn patients from Imam Reza Burn Center (Mashhad, Iran) over 9 years. The outcomes of interest were mortality, length of hospital stay, and the Abbreviated Burn Severity Index (ABSI). Also, we measured the distance between the patient referral location to Mashhad. SPSS version 16 was used for data analysis. Overall, 52.7% of admitted patients were referred from hospitals in other cities. The referred group had more severe burn injury (P < .001), higher mortality rate (P < .001), and longer length of hospital stay (P < .001). The referred distance was associated with an increased risk of death (Odds ratio = 1.68, 95% CI, 1.47-1.92), but after controlling the severity of burns, only ABSI was the statistically significant predictor of mortality (Odds ration = 2.17, 95% CI, 2.05-2.28). Therefore, increasing the distance from urban areas to specialized burn center did not increase the mortality rate. After adjusting for ABSI, the mortality rate in referred patients was not related to referral distance. By observing referral points based on available guidelines, distance from a referral burn center does not affect mortality rate independently. Therefore, equipping the existing burn centers instead of building new ones and focusing on improving referral system can be a good strategy in low- and middle-income countries with limited resources.

Evaluation of silver sulfadiazine 1%-cerium nitrate 2.2% cream efficacy and safety in moderate to severe burn patients: a single-blind randomized clinical trial.

BACKGROUND: Burn injury is a major global health crisis. Topical antimicrobials such as silver sulfadiazine (SSD) are commonly used for superficial burn wounds. SSD has a broad-spectrum antimicrobial activity and also anti-inflammatory property, but also suffers from some limitations. Therefore, some studies suggest to add cerium nitrate (CN) to SSD, as an immunomodulatory and tanning agent with antitoxic properties, but its effect on patients' mortality, length of hospital stay, and bacterial colonization is contraversial. OBJECTIVES: In this research, we evaluated the efficacy and safety of SSD 1%+CN 2.2% cream in patients with moderate to severe burn. MATERIAL AND METHODS: Twenty-two patients who fulfilled the inclusion criteria randomly were assigned to the intervention (n=7) or control (n=15) group and received SSD 1%+CN 2.2% or SSD cream 1% respectively, once daily until the complete re-epithelization or prepration of the burned skin for grafting. Intesity of pain, re-epithelialization time, required interventions, laboratory and clinical findings and final outcome were recorded. RESULTS: There was no significant difference in re-epithelialization time between the treatment and control groups (P>0.05). The same findings were reported about the required interventions and laboratory and clinical parameters. However, the final outcome and the pain score on third day were significantly better in the treatment group (P=0.017). On the other hand, all patients in the treatment group needed graft surgery. CONCLUSION: Use of SSD 1%+CN 2.2% cream did not significantly improve re-epithelization time or infection occurrence and patients' pain, but also increased graft surgery rate in comparison with SDD 1% cream in moderate to severe burns.

Rehabilitation of Burn Victims: Improving Quality of Life in Victims With Face and Neck Burn Through an Augmented Reality Coupled Pamphlet.

The present study aimed to investigate the effect of implementing rehabilitation programs using an augmented reality (AR) coupled pamphlet on the quality of life (QOL) of patients with face/neck burns. This randomized clinical trial was conducted on 60 patients (intervention = 30, control = 30) admitted to the burn center of Imam Reza Hospital, Mashhad, Iran. Patients in the intervention group performed their rehabilitation program using AR coupled pamphlet during 6 weeks, while control patients used simple pamphlet. The Burn-Specific Health Scale for Face and Neck (BSHS-FN) was completed at the beginning, and 2 and 6 weeks after the intervention. The results for 2 weeks after intervention measures in model 1 ANCOVA showed significant raise of measures only for Hand function (P = .035). However, for the total QOL score and other domains the differences were not significant (All P > .05). Adjusting for confounders, model 2 ANCOVA showed similar results for 2 weeks after intervention. However, in both models, the results indicated significant intervention effect for 6 weeks after intervention in QOL score and all domains (All P < .05), so that the amount of increase in measures were significantly higher in the intervention group. According to the findings, implementing rehabilitation program for patients with face and neck burns using AR coupled pamphlet can improve their QOL.

Extensive monomicrobial necrotizing fasciitis and myonecrosis of left hemi trunk in a healthy 41-year-old man with COVID-19 infection.

Necrotizing fasciitis and myonecrosis caused by Escherichia coli is an extremely uncommon infection with a high mortality. We present a case of 41-year-old man with no history of underlying disease one week after covid-19 infection, who was admitted with symptoms of Fournier's gangrene and then E. coli-induced monomicrobial necrotizing fasciitis.

Modified Sol-Gel Synthesis of Mesoporous Borate Bioactive Glasses for Potential Use in Wound Healing.

In this study, we successfully utilized nitrate precursors for the synthesis of silver (Ag)-doped borate-based mesoporous bioactive glass (MBGs) based on the 1393B3 glass formulation in the presence of a polymeric substrate (polyvinyl alcohol (PVA)) as a stabilizer of boric acid. The X-ray diffraction (XRD) analysis confirmed the glassy state of all the MBGs. The incorporation of 7.5 mol% Ag into the glass composition led to a decrease in the glass transition temperature (Tg). Improvements in the particle size, zeta potential, surface roughness, and surface area values were observed in the Ag-doped MBGs. The MBGs (1 mg/mL) had no adverse effect on the viability of fibroblasts. In addition, Ag-doped MBGs exhibited potent antibacterial activity against gram-positive and gram-negative species. In summary, a modified sol-gel method was confirmed for producing the Ag-doped 1393B3 glasses, and the primary in vitro outcomes hold promise for conducting in vivo studies for managing burns.

The Effect of a Recreational Therapy Program on the Pain Anxiety and Quality of Life of Patients With Burn Injuries: A Randomized Clinical Trial.

Pain anxiety and dysfunction are among the most prevalent complications of burns, impacting the quality of life (QOL) of patients with burn injuries. As a nonpharmaceutical approach, recreational therapy can be effective in reducing the complications of burns. This study aimed to examine the effect of a recreational therapy program on the pain anxiety and QOL of patients with burn injuries. This controlled randomized clinical trial was conducted on 58 patients admitted to the burn center of Imam Reza Hospital in Mashhad, Iran. These patients were randomly allocated to the intervention and control group. The intervention group received a recreational therapy program three sessions a week, for 2 weeks. The control group performed routine daily activities. As the main variable of the study, the Burn Specific Pain Anxiety Scale and Burn Specific Health Scale-Brief were completed for both groups before and 2 weeks after the intervention. After controlling confounders, the pain anxiety score in the intervention group was significantly lower than in the control group (P = .002). The total QOL score was significantly higher in the intervention group than the control group (P = .001). In addition, the intervention significantly increased the scores of QOL in the physical (P < .001), emotional (P = .009), and social (P < .001) dimensions. As it reduces pain anxiety and promotes the QOL of patients with burn injuries, this recreational therapy program is recommended for promoting the mental health and QOL of these patients.

Improving respiratory muscle strength and health status in burn patients: a randomized controlled trial.

PURPOSE: Pulmonary complications are among the major disadvantages of burns. The present study aimed to determine the effect of inspiratory muscle training on respiratory muscle strength and health status in burned patients. METHODS: The current randomized clinical trial was conducted on 64 burned patients in Burn Center of Imam Reza Hospital, Mashhad, Iran. In the intervention group, a Powerbreathe device (KH1 digital model) was used twice a day for 10 days, accompanied by the routine procedures and in the control group, only chest physiotherapy and incentive spirometer were used. RESULTS: Before the intervention, the mean scores of respiratory muscle strength were 38.8 ± 10.1 and 35.8 ± 9.0 in the Powerbreathe group and control group, respectively (p = .206). After the intervention, the mean score of respiratory muscle strength of Powerbreathe group was 49.2 ± 11.8 and in the control group was 39.3 ± 8.5 (p < 0.001). Moreover, the mean scores of health status before the intervention in the burned patients were 66.3 ± 14.8 and 63.0 ± 17.3 in the Powerbreathe group and control group, respectively (p = 0.550). In the post-intervention phase, the mean health status score of the burned patients in the intervention and control groups were measured at 75.9 ± 14.1 and 66.7 ± 15.9, respectively (p = 0.019). CONCLUSION: It seems that inspiratory muscle training improves respiratory muscle strength and health status in the burned patients. Therefore, the use of Powerbreathe is recommended for the prevention and improvement of pulmonary complications in patients with chest burns.

An unprecedented increase in burn injuries due to alcohol-based hand sanitizers during the COVID-19 outbreak.

Background: Due to the COVID-19 outbreak, protective measures including alcohol-based hand rub, received unexampled popularity in Iran. Alcohol hand rub is effective, inexpensive and simple to use, but it is a flammable liquid, which might cause burn injuries. In this study, we investigated burn injuries due to alcohol hand sanitizers during the COVID-19 disease outbreak in Iran. Methods: This cross-sectional study was performed on burn patients referred to Motahari Burns and Reconstruction Center from February 20th, 2020 (official announcement of the epidemic of COVID-19 in Iran) up to April 19th, 2020. All outpatients and hospitalized burn injuries caused by alcohol during the abovementioned period were included. Results: There were 76 burn injuries due to the use of alcohol hand sanitizer. Sixty patients were treated outpatient, and 16 were hospitalized. The mean ± SD age of patients was 33.2±17.9 years and most were males (57 individuals, 75%). Also, the mean ± SD of TBSA was 6.1±6.5%. In hospitalized ones, the mean ± SD hospital stay was 11.7±8.6 days. The most burnt area was the head (39.5%) followed by the right upper limb (35.5%) and the left upper limb (23.7%). Patients were actively engaged in burn injury in 61.8% of cases, while they were passively burnt in 34.2% of cases and in 3.9% the mechanism was unknown. Burn injuries mostly happened in the yard (22.4%) followed by the rooftop (21.1%) and outdoors (18.4%). Conclusion: Appropriate general education, especially through mass media, can reduce burns caused by alcohol-based sanitation during the COVID-19 outbreak. Most of these burn injuries involved face and hands, which are cosmetically and functionally important.

The effect of rehabilitation education through social media on the quality of life in burn patients: a randomized, controlled, clinical trial.

BACKGROUND: Burn is one of the most brutal harms to the human body and mind and its wide-ranging complications have many adverse effects on the patients' quality of life. The present study was conducted to investigate the effect of rehabilitation education through social media on burn patients' quality of life. METHODS: The present randomized, controlled, clinical trial was conducted on 60 patients admitted to Imam Reza Hospital Burn Center in the city of Mashhad, Iran, who were randomly assigned to either the intervention or control groups (n = 30 per group). The researcher then created a WhatsApp channel to provide educational content and a WhatsApp group for burns patients to join and get their questions answered. The intervention group patients pursued their post-discharge education through the social media for a month. The control group patients received their discharge education according to the ward's routine procedures through pamphlets and face-to-face training by the personnel. As the study's main variable, the Burn Specific Health Scale-Brief was completed by both groups before and 1 and 2 months after the intervention. Data were analyzed using the ANCOVA and repeated-measures ANOVA. RESULTS: There was no significant differences between the intervention and control groups in terms of the QOL score and any of the domains at baseline. The results indicated the significant effect of the intervention both 1 and 2 months post-intervention on the QOL score and all the domains (P < 0.05), except for body image (Pmodel1 = .550 and  Pmodel2 = .463) and skin sensitivity (Pmodel1 = .333 and Pmodel2 = .104). CONCLUSION: The post-discharge rehabilitation education of burns patients through social media improves their quality of life and can be used as an appropriate educational and follow-up method in different stages of the rehabilitation of burn patients. TRIAL REGISTRATION NO. : IRCT20190622043971N1, 05-10-2019.

Cerium Oxide Nanoparticles (Nanoceria): Hopes in Soft Tissue Engineering.

Several biocompatible materials have been applied for managing soft tissue lesions; cerium oxide nanoparticles (CNPs, or nanoceria) are among the most promising candidates due to their outstanding properties, including antioxidant, anti-inflammatory, antibacterial, and angiogenic activities. Much attention should be paid to the physical properties of nanoceria, since most of its biological characteristics are directly determined by some of these relevant parameters, including the particle size and shape. Nanoceria, either in bare or functionalized forms, showed the excellent capability of accelerating the healing process of both acute and chronic wounds. The skin, heart, nervous system, and ophthalmic tissues are the main targets of nanoceria-based therapies, and the other soft tissues may also be evaluated in upcoming experimental studies. For the repair and regeneration of soft tissue damage and defects, nanoceria-incorporated film, hydrogel, and nanofibrous scaffolds have been proven to be highly suitable replacements with satisfactory outcomes. Still, some concerns have remained regarding the long-term effects of nanoceria administration for human tissues and organs, such as its clearance from the vital organs. Moreover, looking at the future, it seems necessary to design and develop three-dimensional (3D) printed scaffolds containing nanoceria for possible use in the concepts of personalized medicine.

The Curious Cases of Burn by Fig Tree Leaves.

Phytophotodermatitis is a condition which is caused by contact with some plants containing furocoumarins. Furocoumarins in sap of fig tree are the main cause of its irritability when come in contact with the skin. The main symptoms are burning sensation and pain, itchy erythema, and edema, which usually begin 24 h after exposure. The leaf and root sap of the fig tree are the most potent parts causing irritant reaction. We report four children who were playing with fig tree leaves during a family picnic. They were referred to a burn center with second-degree burn in about 10% of total body surface area, due to phytophotodermatitis. Most people are not aware of the potential adverse effect of the plant. The improvement in general knowledge about the dangers of contacting fig tree leaves and sap and the benefits of suitable coverage at the time of harvesting or contacting fig tree may prevent such adverse effects.

Lethal area 50 percent (LA50) or standardized mortality ratio (SMR): Which one is more conclusive?

BACKGROUND: Burn injuries impose a considerable burden on healthcare systems. It is among the top ten causes of mortality and a major cause of disability. This study aimed to calculate and compare the lethal area fifty percent (LA50) and standardized mortality ratio (SMR) in patients with burns. METHODS: This is a five-year cross-sectional study. The study population consisted of 3284 patients with acute burns who were admitted to the Burn Department of Imam Reza Hospital in Mashhad, Iran, from 2010 to 2015. LA50 and SMR were calculated. SPSS 16 was used for logistic regression analysis. RESULTS: The mean percentage of burn total body surface area (TBSA%) was 37.0 (25.5), and deceased patients with burns had a significantly higher burn TBSA% than alive discharged patients (70.3 (24.2) vs. 28.1 (17.1), p<0.001). The most common cause of burn was fire (71.7%). The total case fatality rate was 21.2%. However, this index was more than double in females than in males (31.9% vs. 14.3%, p<0.001). The SMR, based on the abbreviated burn severity index (ABSI), increased from 61% to 80% during the 5-year period. LA50 for total admitted patients was 63.8% (95% confidence interval [CI]=60.4-67.7). LA50 for scalds was the highest (72.1%) compared to those of other types of mechanisms of burn injuries. TBSA, age, and gender were found to be mutually independent predictors of death. CONCLUSION: The trend of LA50 in these five years declined by 12%, whereas the SMR was below 100%. Improvement in burn management quality in high-risk groups including the elderly, females, and patients with extensive burns may improve LA50 in burn units. However, LA50 alone is not a conclusive index for the performance of a burn department, and it should be interpreted alongside with SMR.

Endogenous Endophthalmitis after Severe Burn: A Case Report.

PURPOSE: This report describes a rare ocular complication in a burned patient. CASE REPORT: A 12-year-old girl was admitted to our burn center because of full thickness burn of 46% of her total body surface area. On the 23rd day of her stay, she complained of pain and decreased visual acuity in the right eye. Examination of this eye revealed panuveitis, dense vitritis, and a large chorioretinal abscess in the macular area; her best corrected visual acuity (BCVA) in this eye was hand motion. The left eye was completely normal. A smear and culture of the vitreous biopsy revealed the presence of Candida albicans. With a diagnosis of endogenous endophthalmitis due to fungal infection, the patient was treated with systemic fluconazole, intravitreal injection of Amphotericin B, and pars plana deep vitrectomy. After 6 months, the patient's final ocular examination revealed BCVA of counting fingers at two meters, a large macular scar, and quiescence of the intraocular infection. CONCLUSION: Burn patients treated with broad-spectrum antibiotics are at risk of candidemia and its complications, including endogenous endophthalmitis. Early diagnosis of endogenous endophthalmitis in high risk patients could prevent visual loss.

Skin allograft procurement and transplantation in Mashhad, Iran: Are burn patients' needs being met?

Only a single donor's tissue may save or improve lives of one hundred patients. Unfortunately, low governmental and media support of tissue procurement and transplantation programs is a worldwide problem. Loss of an effective tissue procurement program in many countries like Iran, may lead to loss of many thousands valuable tissues each year. To evaluate the rate of skin donation in Mashhad in comparison to other organs and tissues, we extracted the data related to tissue and organ procurement in Mashhad from 2001. Then we evaluated the annual skin allograft needs in the Burn Department of Imam Reza Hospital as the only referral burn center in the northeast of Iran. Brain dead potential donation rate per million populations of Mashhad in the years 2007-2014 was about 33. The mean refusal rate was 51%. Of patients who have consent for donation, more than 86% have consent for skin donation. Skin allograft procured from 119 (35.5%) candidates. Average of skin retrieval per cadaveric was 1525 cm2 with a gradual increase from 1400 cm2 in the first year to 1800 cm2 in the last year. The recipient to donor ratio was 1.14. It is estimated that about 1 cm2 of skin allograft is needed for any cm2 burnt body surface area. Considering more than 700 acute burn hospitalization in our burn unit, the patients need for skin allograft would be more than 3.5 million cm2, annually. The annual amount of skin procurement in Mashhad has been currently about 20,000 cm2. It shows that our patients demand is higher than supply. Skin procurement and transplantation is a simple procedure which can be as lifesaving as organ procurement and transplantation. But there isn't any national organization to regulate tissue procurement, banking and transplantation. Governmental support of skin procurement and transplantation programs especially nonprofit programs may improve skin procurement rate and save more lives of severely burnt patients.

Can Skin Allograft Occasionally Act as a Permanent Coverage in Deep Burns? A Pilot Study.

BACKGROUND: Skin allograft is the gold standard of wound coverage in patients with extensive burns; however, it is considered as a temporary wound coverage and rejection of the skin allograft is considered inevitable. In our study, skin allograft as a permanent coverage in deep burns is evaluated. METHODS: Skin allograft survival was assessed in 38 patients from March 2009 to March 2014, retrospectively. Because of the lack of tissue specimen from the skin donors, patients with long skin allograft survival in whom the gender of donor and recipient of allograft was the same were excluded. Seven cases with skin allograft longevity and opposite gender in donor and recipient were finally enrolled. A polymerase chain reaction (PCR) test on the biopsy specimen from recipients and donors were undertaken. RESULTS: PCR on the biopsy specimen from recipients confirmed those specimens belong to the donors. All patients received allograft from the opposite sex. Two (28.57%) patients received allograft from their first-degree blood relatives, and in one (14.29%) case, the allograft was harvested from an alive individual with no blood relation. The rest were harvested from multiorgan donors. In eight months of follow up, no clinical evidence of graft rejection was noted. CONCLUSION: Long term persistence of skin allograft in patients is worthy of more attention. Further studies An increase in knowledge of factors influencing this longevity could realize the dream of burn surgeons to achieve a permanent coverage other than autograft for major burn patients.

Impact of Climate and Environmental Factors on West Nile Virus Circulation in Iran.

BACKGROUND: Geographic distribution of West Nile virus (WNV) is heterogeneous in Iran by a high circulation in the southern-western areas. The objective of our study was to determine environmental and climatic factors associated with the risk of WNV equine seropositivity in Iran. METHODS: Serological data were obtained from a serosurvey conducted in equine population in 260 districts in Iran. The climate and environmental parameters included in the models were distance to the nearest wetland area, type of stable, Normalized Difference Vegetation Index (NDVI), annual mean temperature, humidity and precipitation. RESULTS: The important risk factors included annual mean temperature, distance to wetlands, local and seasonal NDVI differences. The effect of local NDVI differences in spring was particularly notable. This was a normalized difference of average NDVI between two areas: a 5 km radius area centered on the stable and the 5-10 km surrounding area. CONCLUSION: The model indicated that local NDVI's contrast during spring is a major risk factor of the transmission of West-Nile virus in Iran. This so-called oasis effect consistent with the seasonal production of vegetation in spring, and is associated to the attractiveness of the local NDVI environment for WNV vectors and hosts.

The Best Anticoagulation Therapy in Multiple-Trauma Patients with Mechanical Heart Valves: Evaluation of Latest Guidelines and Studies.

BACKGROUND: It is common practice for patients with prosthetic cardiac devices, especially heart valve prosthesis, arterial stents, defibrillators, and pacemaker devices, to use anticoagulation treatment. When these patients suffer from multiple trauma after motor vehicle accidents, the best medical management for this challenging position is mandatory. This strategy should include a rapid diagnosis of all possible multiple organ injuries, with special attention to anticoagulation therapy so as to minimize the risk of thromboembolism complication in prosthetic devices. In this review, we describe the best medical management for patients with multiple trauma who use anticoagulants after heart valve replacement. METHODS: We searched electronic databases PubMed/Medline, Scopus, Embase, and Google Scholar using the following terms: anticoagulant, warfarin, heparin, and multiple trauma. Also, similar studies suggested by the databases were included. Non-English articles were excluded from the review. RESULTS: For patients who use anticoagulation therapy, teamwork between cardiac surgeons, general surgeons, anesthesiologists, and cardiologists is essential. For optimal medical management, multiple consults between members of this team is mandatory for rapid diagnosis of all possible damaged organs, with special attention to the central nervous system, chest, and abdominal traumas. With this strategy, it is important to take note of anticoagulation drugs to minimize the risk of thromboembolism complications in cardiac devices. CONCLUSION: The best anticoagulant agents for emergency operations in patients with multiple trauma who are using an anticoagulant after heart valve replacement are fresh frozen plasma (FFP) and prothrombin complex concentrates (PCC).