Hand Injury among Patients Visiting Emergency Department in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: The hand is a complex organ responsible for activities of daily living, making it susceptible to injuries and accidents. Hand injuries can result in significant functional impairment and it occurs in a younger productive age group. Therefore, it is important to understand the prevalence and patterns of hand injuries. The aim of the study was to find out the prevalence of hand injuries among patients visiting the emergency department of a tertiary care centre. Methods: A descriptive cross-sectional study was in the Emergency Department of a dedicated trauma centre from 1 June 2022 to 31 August 2022. Ethical approval was obtained from the Institutional Review Board (Reference number: 148412078179). Demographic profile, pattern, and mechanism of hand Injuries of all 96 consecutive patients were assessed after taking informed consent. Convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. Results: Among 4679 patients visiting the emergency department of the trauma centre, hand injuries were seen in 96 (2.05 %) (1.64-2.46, 95% Confidence Interval). Conclusions: The prevalence of hand injuries was found to be lower than in other similar studies done in similar settings. Keywords: finger injuries; hand injuries; occupational injuries.

Online Speech Therapy for Cleft Palate Patients in Rural Nepal: Innovations in Providing Essential Care during COVID-19 Pandemic.

BACKGROUND: Speech therapy is important for ideal functional outcome after cleft palate surgery. Nationwide lockdown due to outbreak of COVID-19 in Nepal restricted the ability of patients to travel to nearby outreach centers for regular speech therapy. The objectives were to assess the feasibility and challenges of conducting online speech therapy with postpalatoplasty children during COVID-19 pandemic; and evaluate the ways to overcome them. METHODS: Patients with cleft palate surgery done at least 3 months prior were given online speech therapy. Feasibility, advantages and challenges of online speech therapy were evaluated through interviewing the guardians and speech therapy providers. RESULTS: A total of 89 patients were included in the study. Only 11.2% had secondary palatine procedures. Almost all the children (97.8%) had face to face speech therapy prior to study period. Best use of time, use of audiovisual aid, no need to travel and rapid progress were the most commonly perceived strengths of online speech therapy. The most frequent challenges were internet connectivity, unclear voice, lack of direct interaction and unstable power supply. Recommended ways to improve online speech therapy were cited as better internet connectivity, having a fixed schedule and availing free or affordable Wifi. CONCLUSIONS: Despite the challenges, online speech therapy provided us with a way to reach out to the cleft palate children when face-to-face therapy was not possible due to COVID-19 pandemic. We see its role even during non-pandemic situations for the children who are unable to visit the speech therapy centers.

Mobile Surgical Scouts Increase Surgical Access for Patients with Cleft Lip and Palate in Nepal.

Background: In Nepal's remote regions, challenging topography prevents patients with cleft lip and palate (CLP) from seeking care. Objective: To measure the effect of a mobile surgical scout program on CLP surgical care in remote regions of Nepal. Methods: Forty-four lay people were trained as mobile surgical scouts and over 5 months traversed remote districts of Nepal on foot to detect and refer CLP patients for surgical care. Surgical patients from remote districts were compared with matched time periods in the year before intervention. Diagnostic accuracy of the surgical scouts was assessed. Findings: Mobile surgical scouts accurately diagnosed (90%) and referred (82%) patients for cleft surgery. Before the intervention, CLP surgeries from remote districts represented 3.5% of cleft surgeries performed. With mobile surgical scouting, patients from remote districts comprised 8.2% of all cleft surgeries (p = 0.007). When transportation and accompaniment was provided in addition to mobile surgical scouts, patients from remote districts represented 13.5% (p ≤ 0.001) of all cleft surgeries. Conclusion: Task-shifting the surgical screening process to trained scouts resulted in accurate diagnoses, referrals, and increased access to cleft surgery in remote districts of Nepal.

Plastic Surgical Procedures for Lower Limb Reconstruction at a Tertiary Hospital in Nepal.

BACKGROUND: This study assessed the lower limb reconstruction outcome so that it will provide a baseline evidence to enable data-driven decision making to improve outcome in the future. METHODS: In this study, hospital records from 1st January to 31st December 2019 were collected retrospectively. Complete data of all patients' records treated for lower limb defects at Kirtipur Hospital were included and incomplete data were excluded. Univariate and Bivariate analyses were performed Results: In total 110 patients were included in this study with a male predominance of 66.4% (n=73). The mean age of the patients was 38.7 years (+/- 20). The majority of the patients were from outside Kathmandu valley 79.1% (n=87) and referred 55.5% (n=61). The commonest cause of lower limb defects was trauma 69.1% (n=76), the procedure performed was skin graft 48.5% (n=72), and complication was wound infections, 43% (n=13) of total complications. The hospital stay of more than two weeks was more common among the referred patients 63.9% (n=39) as compared to non-referred patients 30.6% (n=15) and trauma etiology 34.2% (n=26) had more complications than other etiology. The mean age of patients with complications (32.4 years) was lower than those without complications (41.1 years). More number of referred patients (n=43) required multiple surgeries than non-referred patients (n=21). CONCLUSIONS: Referred cases were more likely to have multiple surgeries and a longer hospital stay than non-referred cases. Infection was the commonest complication and the majority of complications were seen in trauma and younger age group.

Comparison of accidental pediatric scald burns in a tertiary care center: hot cauldron burns versus accidental spill burns.

Background: Scald burns result from exposure to high-temperature fluids and are more common in the pediatric age group. They occur mainly by two mechanisms: (i) spill and (ii) immersion (hot cauldron) burns. These two patterns differ in clinical characteristics and outcomes. Scalds cause significant morbidity and mortality in children. The objective of this study was to compare accidental spill burns and hot cauldron burns in a hospital setting. Methods: An analytical cross-sectional study was conducted by reviewing the secondary data of scald cases admitted during the years 2019 and 2020 in a burn-dedicated tertiary care center. Total population sampling was adopted. Data analysis was done partly using SPSS, version-23, and Stata-15. Mann Whitney U-test and Chi-square/Fisher's exact test were done appropriately to find associations between different variables. Regression analysis was performed taking mortality events as the outcome of interest. Results: Out of 108 scald cases, 43 (39.8%) had hot cauldron burns and 65 (60.2%) had accidental spill burns. Overall mortality was 16 (14.8%), out of which hot cauldron burns and accidental spill burns comprised 12 (75.0%) and 4 (25.0%), respectively. Multinomial logistic regression analysis showed the type of scald, age, and Baux score found to be associated with mortality. Every one-year increment in age had a 29% lower odds of occurrence of mortality event (adjusted odds ratio [OR], 0.71; 95% confidence interval [CI], 0.50-0.99, p=0.042). Likewise, every one-point increment in Baux score was associated with 19% higher odds of mortality (adjusted OR, 1.190; 95% CI, 1.08-1.32; p<0.001). Conclusions: Accidental spill burns were more common but mortality was significantly higher for hot cauldron burns. The majority of burn injuries occurred inside the kitchen emphasizing appropriate parental precautions. The risk of mortality was significantly higher in burn events occurring outside the house, and burns involving back, buttocks, perineum, and lower extremities.

Evaluation of an Antimicrobial Stewardship Program for Wound and Burn Care in Three Hospitals in Nepal.

Antimicrobial stewardship (AMS) programs can decrease non-optimal use of antibiotics in hospital settings. There are limited data on AMS programs in burn and chronic wound centers in low- and middle-income countries (LMIC). A post-prescription review and feedback (PPRF) program was implemented in three hospitals in Nepal with a focus on wound and burn care. A total of 241 baseline and 236 post-intervention patient chart data were collected from three hospitals. There was a significant decrease in utilizing days of therapy per 1000 patient days (DOT/1000 PD) of penicillin (p = 0.02), aminoglycoside (p < 0.001), and cephalosporin (p = 0.04). Increases in DOT/1000 PD at post-intervention were significant for metronidazole (p < 0.001), quinolone (p = 0.01), and other antibiotics (p < 0.001). Changes in use of antibiotics varied across hospitals, e.g., cephalosporin use decreased significantly at Kirtipur Hospital (p < 0.001) and Pokhara Academy of Health Sciences (p = 0.02), but not at Kathmandu Model Hospital (p = 0.59). An independent review conducted by infectious disease specialists at the Henry Ford Health System revealed significant changes in antibiotic prescribing practices both overall and by hospital. There was a decrease in mean number of intravenous antibiotic days between baseline (10.1 (SD 8.8)) and post-intervention (8.8 (SD 6.5)) (t = 3.56; p < 0.001), but no difference for oral antibiotics. Compared to baseline, over the 6-month post-intervention period, we found an increase in justified use of antibiotics (p < 0.001), de-escalation (p < 0.001), accurate documentation (p < 0.001), and adherence to the study antibiotic prescribing guidelines at 72 h (p < 0.001) and after diagnoses (p < 0.001). The evaluation data presented provide evidence that PPRF training and program implementation can contribute to hospital-based antibiotic stewardship for wound and burn care in Nepal.

Prevalence of Dental Anomalies in the Patient with Cleft Lip and Palate Visiting a Tertiary Care Hospital.

INTRODUCTION: Dental anomaly is one of the major problems in a child born with cleft lip and palate. These anomalies have deleterious effects on the dentition leading to aesthetic problems, impairment of mastication andimproper phonation. The aim of our study was to find out the prevalence of dental anomalies in patient with cleft lip and/or palate radiographically. METHODS: A descriptive cross-sectional study was conducted from the 208 radiographs, collected by the convenience samplingtechnique with cleft lip and/or palate in Department of Burns, Plastic and Reconstructive Surgery, Nepal Cleft and Burn Centre, Kirtipur Hospital from January 2017 to July 2019.Ethical clearance for the study was obtained from Institutional Review Committee. Demographic data were collected and radiographs were evaluated for possible dental anomalies. Data obtained were entered and analysed in Statistical Package for Social Sciences version 23. RESULTS: Dental anomalies were highly prevalent among cleft lip and palate patients with at least one anomaly present in 188 (90.4%) of patients with male 120 (57.4%) presenting more anomalies than female 88 (42.6%) population. The most common anomaly was dental agenesis 161 (77.9%). The prevalence of positional anomaly, morphological anomaly and supernumerary teeth were found to be 54 (26%), 33 (15.9%) and 20 (10%) respectively. Lateral incisor showed the highest incidence of agenesis among all other missing teeth 223 (65.2%). CONCLUSIONS: The prevalence of dental anomalies among patients with cleft lip and/or palate was found to be high. Tooth agenesis was the most common anomaly observed in the study with lateral incisor having the highest incidence of agenesis.

Optimizing speech outcomes for cleft palate.

PURPOSE OF REVIEW: Cleft lip with or without palate is one of the most common pediatric birth anomalies. Patients with cleft palate often have speech difficulties from underlying anatomical defects that can persist after surgery. This significantly impacts child development. There is a lack of evidence exploring, which surgical techniques optimize speech outcomes. The purpose of this update is to report on recent literature investigating how to optimize speech outcomes for cleft palate. RECENT FINDINGS: The two-flap palatoplasty with intravelar veloplasty (IVVP) and Furlow double-opposing Z-plasty has the strongest evidence for optimizing speech. One-stage palatal repair is favored at 10-14 months of age, while delays are associated with significant speech deficits. For postoperative speech deficits, there is no significant difference between the pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation. Surgical management should be guided by closure pattern and velopharyngeal gap but few studies stratify by these characteristics. SUMMARY: According to recent evidence, the two-flap palatoplasty with IVVP and Furlow palatoplasty result in the best speech. The pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation are all viable techniques to correct residual velopharyngeal insufficiency. Future research should focus on incorporating standardized measures and more robust study designs.

A task-shifted speech therapy program for cleft palate patients in rural Nepal: Evaluating impact and associated healthcare barriers.

INTRODUCTION: Though access to surgical care for cleft lip/palate has expanded in low- and middle-income countries (LMICs), post-palatoplasty speech therapy is often lacking due to limited healthcare infrastructure and personnel. This mixed-methods study seeks to: 1) evaluate the impact of task-shifted speech therapy on a standardized speech score; 2) describe the experiences of families with post-operative cleft care and associated barriers; and 3) understand how to optimize cleft care by exploring the experiences of children who had nominal improvements after task-shifted speech therapy. METHODS: A convergent parallel mixed-methods study was conducted in Nepal. Standardized speech scores were compared by a blinded speech-language pathologist before and after the speech intervention. Semi-structured interviews (SSIs) and focus groups with families evaluated cleft care experiences and barriers. Qualitative and quantitative data were merged and analyzed. RESULTS: Thirty-nine post-palatoplasty children with speech deficits (ages 3-18) underwent task-shifted speech therapy, and demonstrated significant improvements in composite speech scores targeted by exercises (p<0.0001) and weakness (p=0.0002), with improvements in misarticulation (p=0.07) and glottal stop (p=0.05) that trended towards significance. Forty-seven SSIs demonstrated that the greatest barriers to follow-up were family responsibilities (62%), travel/distance (53%), and work (34%). In five focus groups, families expressed a desire to improve their child's speech and seek formal speech therapy. The speech intervention was found to be beneficial because of the compassionate staff, free lodging/food, and ability to socialize with other cleft patients and families. After merging quantitative and qualitative data, we noted that younger children between 3 and 5 years old and families who traveled greater distances for healthcare access benefited less from the speech therapy intervention. CONCLUSIONS: Task-shifted speech therapy has the potential to improve cleft lip/palate speech in LMICs. Multiple biosocial issues limit access to appropriate post-operative care.

Nepali Linguistic Validation of the Velopharyngeal Insufficiency Effects on Life Outcomes Instrument: VELO-Nepali.

OBJECTIVE: To translate and validate the velopharyngeal insufficiency (VPI) effects on life outcomes (VELO) instrument into Nepali, and test its internal consistency and validity. DESIGN: Quality-of-life instrument translation and validation. SETTING: Community served by Nepal's craniofacial referral hospital. PARTICIPANTS: Twenty-three postpalatoplasty children with VPI, 19 family guardians of VPI cases, and 29 non-VPI controls. INTERVENTIONS: The VELO instrument was translated to Nepali by 2 independent bilingual translators, reconciled, backward-translated, compared, and modified using patient cognitive interviews. All VPI children, guardians, and controls completed the VELO-Nepali. MAIN OUTCOME MEASURE(S): The VELO internal consistency was evaluated using Cronbach α coefficient. Concurrent validity and discriminant validity were assessed using 2-sample t test: assuming unequal variances. RESULTS: The VELO was translated and optimized using cognitive interviews. The VELO-Nepali demonstrated excellent internal consistency, with Cronbach α coefficients of 0.93, 0.94, and 0.90 for VPI cases, guardians of VPI cases, and non-VPI controls, respectively. The VELO-Nepali exhibited strong discriminant validity between VPI cases (x¯ = 45.4, standard deviation [SD] = 22.1) and non-VPI controls (x¯ = 84.9, SD = 12.3), (P < .001). The VELO-Nepali showed strong concurrent validity with similarities in VPI case scores (x¯ = 45.4, SD = 22.1), and guardian scores (x¯ = 52.9, s = 22.8; P = .473). CONCLUSION: The translated VELO-Nepali demonstrates strong internal consistency, discriminant validity, and concurrent validity, and can assess quality of life for Nepali VPI patients. This instrument represents the first VPI quality of life assessment validated in Nepali, and supports the feasibility of its implementation in other low- and low-middle-income countries.

Summary of the International Patient Safety Conference, June 28-29, 2019, Kathmandu, Nepal.

Globally, medical errors are associated with an estimated $42 billion in costs to healthcare systems. A variety of errors in the delivery of healthcare have been identified by the World Health Organization and it is believed that about 50% of all errors are preventable. Initiatives to improve patient safety are now garnering increased attention across a range of countries in all regions of the world. From June 28--29, 2019, the first International Patient Safety Conference (IPSC) was held in Kathmandu, Nepal and attended by over 200 healthcare professionals as well as hospital, government, and non-governmental organization leaders. During the conference, presentations describing the experience with errors in healthcare and solutions to minimize future occurrence of adverse events were presented. Examples of systems implemented to prevent future errors in patient care were also described. A key outcome of this conference was the initiation of conversations and communication among important stakeholders for patient safety. In addition, attendees and dignitaries in attendance all reaffirmed their commitment to furthering actions in hospitals and other healthcare facilities that focus on reducing the risk of harm to patients who receive care in the Nepali healthcare system. This conference provides an important springboard for the development of patient-centered strategies to improve patient safety across a range of patient care environments in public and private sector healthcare institutions.

Pilot Study to Assess Safety and Usability of the Kyron NPWT System.

There is an evident need for Negative Pressure Wound Therapy (NPWT) systems specifically designed for use in resource-constrained settings to aid in the treatment of open wounds. METHODS: Prospective single-arm interventional pilot study of 14 patients with complex wounds was conducted at Kirtipur Hospital in Kathmandu, Nepal. A novel NPWT device, the Kyron Suction Unit, was used by 4 plastic surgeons. Primary outcomes were ease of use (10-point Likert scale) and device safety (adverse events recorded). Pain (Visual Analogue Scale score), quality of life (modified EuroQol Derived Single Index scores), and wound dimensions were recorded. RESULTS: User ratings on the 10-point Likert scale indicated high confidence and ease of use: median confidence setting up the device of 1.0 [interquartile range (IQR), 1.0; mean 2.3], median confidence maintaining the device of 1.0 (IQR, 1.0; mean, 1.5), and median ease of disassembly of 1.0 (IQR, 1.0; mean, 1.4). Significant improvement in Visual Analogue Scale scores (P = 0.03), modified EuroQol Derived Single Index scores (P < 0.001), and a reduction in wound volume [median, 47.25-9.75 cm3 (P = 0.01)]. Image analysis of wounds pretreatment and posttreatment demonstrated increase in granulation tissue surface area [median, 7.6-28.7 cm2 (P = 0.003)] and decrease in open wound surface area [median, 48.33-33.6 cm2 (P = 0.01)]. CONCLUSIONS: The Kyron Suction Unit was safe and easily managed by plastic surgeons. The device design promoted access to NPWT, a therapy proven to reduce healing time and decrease complications for patients with open wounds, in a resource-constrained setting.

Evaluation of a Hospital-Based Post-Prescription Review and Feedback Pilot in Kathmandu, Nepal.

Capacity building is needed in low- and middle-income countries (LMICs) to combat antimicrobial resistance (AMR). Stewardship programs such as post-prescription review and feedback (PPRF) are important components in addressing AMR. Little data are available regarding effectiveness of PPRF programs in LMIC settings. An adapted PPRF program was implemented in the medicine, surgery, and obstetrics/gynecology wards in a 125-bed hospital in Kathmandu. Seven "physician champions" were trained. Baseline and post-intervention patient chart data were analyzed for changes in days of therapy (DOT) and mean number of course days for intravenous and oral antibiotics, and for specific study antibiotics. Charts were independently reviewed to determine justification for prescribed antibiotics. Physician champions documented recommendations. Days of therapy per 1,000 patient-days for courses of aminoglycoside (P < 0.001) and cephalosporin (P < 0.001) decreased. In the medicine ward, data indicate increased justified use of antibiotics (P = 0.02), de-escalation (P < 0.001), rational use of antibiotics (P < 0.01), and conforming to guidelines in the first 72 hours (P = 0.02), and for definitive therapy (P < 0.001). Physician champions documented 437 patient chart reviews and made 138 recommendations; 78.3% of recommendations were followed by the attending physician. Post-prescription review and feedback can be successfully implemented in LMIC hospitals, which often lack infectious disease specialists. Future program adaptation and training will focus on identifying additional stewardship programming and support mechanisms to optimize antibiotic use in LMICs.

The Bacteriological Profile of Burn Wound Infections at a Tertiary Burns Center in Nepal.

In Nepal, burn is the third most common injury after falls and road traffic accidents. Infection is the leading cause of mortality in burn injury. A profile exploring predominant flora and antimicrobial sensitivity is important to facilitate treatment ahead of microbiology results and to aid prevention of multidrug-resistant organisms. The aim of this study was to document epidemiological and bacteriological data of burn wound infections at a tertiary level burns center in Nepal. Samples were collected from January 2017 to May 2017, over a period of 5 months. Patient notes were referred to and information regarding baseline characteristics and burn wound infection data was collected. A total of 76 patients were included in the study during the 5-month period, which resulted in 113 samples being included for review. Females were injured most with burns 70% (n = 53) compared with males 30% (n = 23). Only 6 (8%) of 77 patients lived locally in Kathmandu. The average distance traveled by patients was 233 km (median 208, range 0-765, SD 181). Average TBSA% of burn was 22% (median 20, range 3-50, SD 12). Gram-negative organisms predominated, with Acinetobacter spp. in 42 cases (55%), Pseudomonas aeruginosa in 26 cases (34%), and Enterobacter spp. in 16 cases (21%). Colistin, polymyxin B, and tigecycline were found to be most sensitive covering 108, 98, and 94 organisms. Gram-negative bacteria colonized the majority of burn wounds. Colistin, polymyxin B, and tigecycline were the most sensitive to gram-negative bacteria. Gram-positive Staphylococcus aureus was sensitive most to vancomycin and tigecycline.

Clinical Epidemiology of Acute Burn Injuries at Nepal Cleft and Burn Centre, Kathmandu, Nepal.

BACKGROUND: Burn injury is a global health problem mainly occurring in developing countries. The Nepal Cleft and Burn Centre at Kirtipur Hospital, Kathmandu, has been providing the acute burn care since 2013 with 7 intensive care unit beds, 30 general beds, and 2 dedicated operating rooms. A similar descriptive study was performed in this center in 2014. These studies will be helpful for developing prevention strategies and monitoring the progress in the standard of care of acute burn patients. METHOD: This is a descriptive retrospective study of the clinical data of acute burn patients admitted from January 1, 2015 to December 31, 2016. RESULTS: There were a total of 567 patients who came from 63 of 75 total districts of Nepal. Two hundred ninety-six (52.2%) patients were females and 271 (47.8%) were males. Two thirds of the patients were young adults. Most of the injuries occurred inside the house (72.1%). Flame burn was the most common mode of injury (66%) followed by scald (21.6%). Only 64 (11.3%) patients arrived on the same day of the injury. The longest time elapsed was 60 days with a median of 4.3 days. Range of total body surface area (TBSA) involved was 1% to 95%. The mean and median TBSAs were 25% and 15%, respectively. Range of hospital stay was 1 to 105 days with a median of 13.3 days.A total of 448 surgical procedures were performed in 384 patients (67.7%). A total of 110 (19.4%) patients died at the hospital. Only 13 patients (3%) survived deep burn injury involving 40% or more TBSA with either cadaveric skin allograft or with skin allograft from the live relatives. CONCLUSIONS: The outcome of burn injuries in Nepal is very poor. Children and females are at high risk. There is a lack of knowledge about burn prevention, proper first aid, and skin donation among the Nepalese population. Delay in presentation and extensive burns are poor prognostic factors. Awareness programs about the proper first aid and the need of a skin bank has to be done to improve the burn scenario in Nepal. Availability of allograft can increase the chances of survivability of patients with extensive burns in Nepal.

Creation of Nepal's First Skin Bank: Challenges and Outcomes.

BACKGROUND: In Nepal, burn trauma causes more than 55,000 injuries each year. Burn-related mortality is high in Nepal, in part due to lack of allograft, leading to high infection rates. To address this challenge, our collaboration between Kirtipur Hospital, America Nepal Medical Foundation, Stanford University, and ReSurge International established Nepal's first skin bank. METHODS: We identified 3 major tasks to create a sustainable skin banking program: 1) identify and acquire the equipment and personnel needed to collect, process, store, and graft cadaveric skin for burn injuries; 2) develop safe donation protocols and documentation tools that remain feasible for low-resource settings; and 3) develop a long-term awareness program to educate the Nepali people on skin donation, a previously foreign concept. RESULTS: Kirtipur Hospital acquired the necessary equipment and materials for the skin bank through a combination of local and international fundraising efforts. Existing U.S. skin banking protocols were adapted for the Nepali setting and piloted on potential patients, donors, and physicians. For the first time in the hospital's history, patients with > 40% total body surface area burns were successfully treated with extensive allografts. CONCLUSIONS: It is feasible to create a skin bank in a country with no tradition of allograft skin use. Long-term sustainability now depends on spreading awareness and education in the Kathmandu Valley to overcome religious and cultural barriers that have hindered donor recruitment. Our low-cost and high-impact skin bank provides a model to expand this system to other hospitals both within Nepal and beyond.

Development of International Outcomes Instrument for Hand and Upper Extremity Burn Scar Contracture Release.

Burn scar contractures remain a common source of severe disability in resource-limited countries. However, existing outcome measurements are unable to fully capture the impact of the scar contracture and surgical attempts at correction. To that end, we have developed a new outcome instrument, the Stanford-ReSurge Burn Scar Contracture Scale-Upper Extremity that can be used as a measurement of disability and reconstructive procedure outcomes. The outcome instrument was created through item generation, item reduction, and preliminary field testing. We performed a literature review using multiple databases to gather a comprehensive list of existing burn contracture metrics, removed metrics that were inapplicable in resource-limited settings, and submitted remaining items to plastic and hand surgeons for evaluation of clinical and cultural relevance, comprehensiveness, and feasibility. The remaining items were field tested to evaluate patient comprehension and ability to detect change over 1 month. A literature review found 32 unique scales that were eventually reduced to a pool of 38 potential items that were field tested with patients. Patient feedback further reduced the item pool to the final 20-item scale. Patients who underwent burn scar contracture release of the upper extremity showed an average of 14 points improvement between the preoperative and 1-month postoperative time point. The Stanford-ReSurge Burn Scar Contracture showed clinical utility for assessing outcomes in burn scar contracture release of the upper extremity. Our goal is to develop a standardized outcome instrument for burn reconstruction in the world's poorest burn patients.

Accuracy of remote burn scar evaluation via live video-conferencing technology.

OBJECTIVE: Telemedicine in outpatient burn care, particularly in burn scar management, may provide cost-effective care and comes highly rated by patients. However, an effective scar scale using both video and photographic elements has not been validated. The purpose of this study is to test the reliability of the Patient and Observer Scar Assessment Scale (POSAS) using live video-conferencing. METHODS: A prospective study was conducted with individuals with healed burn scars in Kathmandu, Nepal. Three independent observers assessed 85 burn scars from 17 subjects, using the Observer portion to evaluate vascularity, pigmentation, thickness, relief, pliability, surface area, and overall opinion. The on-site observer was physically present with the subjects and used a live videoconferencing application to show the scars to two remote observers in the United States. Subjects used the Patient portion to evaluate the scar that they believed appeared the worst appearance and had the greatest impact on function. RESULTS: The single-rater reliability of the Observer scale was acceptable (ICC>0.70) in overall opinion, thickness, pliability, and surface area. The average-rater reliability for three observers was acceptable (ICC>0.70) for all parameters except for vascularity. When comparing Patients' and Observers' overall opinion scores, patients consistently reported worse opinion. CONCLUSIONS: Evaluation of burn scars using the Patient and Observer Scar Assessment Scale can be accurately performed via live videoconferencing and presents an opportunity to expand access to burn care to rural communities, particularly in low- and middle-income countries, where patients face significant access barriers to appropriate follow-up care.

The Stanford-ReSurge Burn Scar Contracture Scale for Neck: Development and Initial Validation for Burn Scar Contracture.

BACKGROUND: Burn contractures can cause significant disability, particularly in patients in resource-limited settings. However, a gap exists in our ability to measure outcomes in patients with burn contractures of the neck. The objective of this study was to develop and validate the Stanford-ReSurge Burn Scar Contracture Scale-Neck to longitudinally assess functional status and measure functional improvement following contracture release of the neck. METHODS: A literature review was performed to identify scales used in neck assessment and burn assessment. Items were then removed from the pool based on redundancy, feasibility, cultural appropriateness, and applicability to patients in international resource-limited environments. Remaining items were administered to patients with burn contracture of the neck. RESULTS: The initial literature review found 33 scales that were combined to create an initial pool of 714 items, which was first reduced to 40 items. Feedback from field testing then yielded a 20-item outcome tool to assess appearance, activities of daily living, somatosensation, satisfaction, and range of motion, with a floor of 20 and a ceiling score of 100 points. Preliminary testing with 10 patients showed an average preoperative score of 58 points and an average 1-month postoperative score of 42 points. CONCLUSIONS: The authors have created an outcome tool for measuring functional status following burn contracture release of the neck, which can easily be implemented in resource-limited settings where the burden of burn injuries and morbidities is disproportionately high. Ongoing work includes a multicountry study to evaluate validity and reliability.

Factors Affecting Burn Contracture Outcome in Developing Countries: A Review of 2506 Patients.

INTRODUCTION: Burn contractures hinder joint mobility, resulting in functional impairment and reduced quality of life. This is of greater significance in developing countries where there are fewer resources for assistance with such impairments. Contracture release reduces deformity, but multiple factors affect the extent of postsurgical improvements and outcomes. Elucidating these factors may enable surgeons to better care for burn patients. This study assesses factors that impact burn contracture resolution in developing nations. METHODS: A retrospective review of 2506 burn contractures was performed using information extracted from a large nongovernment organization (ReSurge International) database from Nepal, India, and Zambia. Data points included age, type of burn, time elapsed between injury and release, and extent of final release achieved based on preoperative and postoperative images of hand (n = 1960), elbow (n = 371), and knee (n = 176) contractures. Hand improvement was scored based on digit/wrist involvement (severity of dysfunction) and joint extension capability (functionality); elbow and knee improvement were calculated using preoperative and postoperative joint angles. Multivariate analysis was performed. RESULTS: Hands burned by hot liquid had greater functionality after surgery than open-fire burns (P < 0.01). Improvement in severity of dysfunction and functionality were inversely correlated to age (P < 0.01) and time until surgery (P < 0.01). Elbow improvement decreased as age increased (P < 0.01). Postoperative increase of knee extension decreased for each year elapsed between injury and surgery (P < 0.01). CONCLUSIONS: Burn type, age when burned, and timing of surgery were significant factors affecting hand outcomes, whereas age affected elbow outcomes, and time elapsed until surgery affected knee results. An algorithm was formulated to enable physicians in developing countries with limited resources to triage patients and optimize patient outcomes.