Burn injuries and acute burn management in the rural areas in northern Bangladesh - A household survey.

INTRODUCTION: Burn injuries pose a significant public health challenge, especially in low- and middle-income countries (LMICs). In Bangladesh, burn injuries are prevalent and often result in severe disability or death. However, knowledge regarding the causes of burn injuries, acute burn management, and barriers to seeking burn care in the riverine areas of northern Bangladesh is limited. METHODS: We conducted a questionnaire-based study in eight subunits and five selected districts in northern Bangladesh to determine the prevalence, causes, and management of burn injuries in these areas. A total of 210 individuals from different households were interviewed, which represented a population of 1020 persons. RESULTS: Among the respondents, 55% reported that at least one member of their household suffered from a burn injury in the past. The most common causes of burn injuries were open fire (41%) and hot fluids (30%). More than 40% of burns were not rinsed with water directly after sustaining the injury. Additionally, almost 30% of respondents did not seek medical care immediately after the injury, with financial constraints being the most commonly cited reason. DISCUSSION: We found a low rate of adequate cooling and seeking medical care. The need for basic knowledge on prevention and treatment of burn injuries and improved access to affordable health care services in the region is high.

Nationwide study on open tibial fractures in the Netherlands: Incidence, demographics and level of hospital care.

OBJECTIVES: Open tibial fractures are relatively common injuries following traffic accidents. The vulnerability of the soft tissues surrounding the tibia increases the susceptibility to complications, including infection and nonunion. To minimize complications, a multidisciplinary, timely approach is crucial. To date, the Dutch incidence and level of hospital treatment remain unknown due to a lack of condition-specific nationwide registries. This study aimed to estimate the incidence and management of open tibial fractures in the Netherlands, providing essential information for public health policymaking and guideline development. METHODS: The 2018 and 2019 Dutch National Hospital Care Basic Registration data, provided by the Dutch Hospital Data Foundation, were utilized to identify all patients admitted to Dutch hospitals with tibial fractures. Incidence rates, patient demographics, primary diagnoses, fracture classification, level of hospital, and length of hospital stays were analyzed using descriptive statistics. RESULTS: 1,079 ICD-10 codes for closed and open tibial fractures were identified in patients that were admitted to a Dutch hospital. Thirty-four percent were classified as open tibial fractures, accounting for an estimated incidence rate of 1.1 per 100,000 person-years (95 % CI 0.97-1.12). When categorized by age, the calculated incidence rate was higher in males for all age categories up until the age of 70. Notably, the overall highest incidence rate was found for females aged 90 and above (6.6 per 100,000 person-years). Open tibial fractures were predominantly treated in general or top clinical hospitals (comprising 69 % of open all tibia fractures). Notably, the minority (31 %) presented at university medical centers, all Level-1 trauma centers, equipped with orthoplastic teams. CONCLUSION: This is the first study to report the nationwide incidence rate of open tibial fractures in the Netherlands; 34 % of tibial fractures were registered as open. Notably, a limited proportion of open tibial fractures underwent treatment within Level-1 trauma centers. Consequently, in the majority of cases, the implementation of an orthoplastic team approach was unattainable. This study underscores the need for more comprehensive data collection to assess and improve the current treatment landscape.

Acute burn care in resource-limited settings: A cohort study on treatment and outcomes in a rural regional referral hospital in Tanzania.

BACKGROUND: Only a few papers are published on the safety and effectiveness of acute burn care in low-income countries. A cohort study was therefore carried out to determine such outcomes. METHODS: The study was conducted in a rural Tanzanian hospital in 2017-2018. All patients admitted with burns were eligible. Complications were scored during admission as an indication for safety. Survivors of severe burn injuries were evaluated for time of reepithelialization, graft take, disability (WHODAS2.0) and quality of life (EQ5D-3L) up to 3 months post-injury, as an indication of effectiveness. RESULTS: Patients presented on average at 5 days after injury (SD 11, median 1, IQR 0-4). Three patients died at admission. The remaining 79 were included in the cohort. Their median age was 3 years (IQR 2-9, range 0.5-49), mean TBSA burned 12% (SD10%) and mortality rate 11.4%. No surgery-related mortality or life-threatening complications were observed. Skin grafting was performed on 29 patients at a delayed stage (median 23 days, IQR 15-47). Complications of skin grafts included partial (25% of procedures) and complete graft necrosis (8% of procedures). The mean time to reepithelialization was 52 (SD 42) days after admission. Disability and quality of life improved from admission to 3 months after injury (p<0.001, p<0.001, respectively). CONCLUSION: In this resource-limited setting patients presented after a delay and with multiple complications. The mortality during the first two weeks after admission was high. Surgery was found to be safe and effective. A significant improvement in disability and quality of life was observed.

The development of burn scar contractures and impact on joint function, disability and quality of life in low- and middle-income countries: A prospective cohort study with one-year follow-up.

OBJECTIVE: The aim of this study was to assess the development of burn scar contractures and their impact on joint function, disability and quality of life in a low-income country. METHODS: Patients with severe burns were eligible. Passive range of motion (ROM) was assessed using lateral goniometry. To assess the development of contractures, the measured ROM was compared to the normal ROM. To determine joint function, the normal ROM was compared to the functional ROM. In addition, disability and quality of life (QoL) were assessed. Assessments were from admission up to 12 months after injury. RESULTS: Thirty-six patients were enrolled, with a total of 124 affected joints. The follow-up rate was 83%. Limited ROM compared to normal ROM values was observed in 26/104 joints (25%) at 12 months. Limited functional ROM was observed in 55/115 joints (48%) at discharge and decreased to 22/98 joints (22%) at 12 months. Patients who had a contracture at 12 months reported more disability and lower QoL, compared to patients without a contracture (median disability 0.28 versus 0.17 (p = 0.01); QoL median 0.60 versus 0.76 (p = 0.001)). Significant predictors of developing joint contractures were patient delay and the percentage of TBSA deep burns. CONCLUSION: The prevalence of burn scar contractures was high in a low-income country. The joints with burn scar contracture were frequently limited in function. Patients who developed a contracture reported significantly more disability and lower QoL. To limit the development of burn scar contractures, timely access to safe burn care should be improved in low-income countries.

Burn scar contracture release surgery effectively improves functional range of motion, disability and quality of life: A pre/post cohort study with long-term follow-up in a Low- and Middle-Income Country.

OBJECTIVE: Burn scar contractures limit range of motion (ROM) of joints and have substantial impact on disability and the quality of life (QoL) of patients, particularly in a Low- and Middle-Income Country (LMIC) setting. Studies on the long-term outcome are lacking globally; this study describes the long-term impact of contracture release surgery performed in an LMIC. METHODS: This is a pre-post cohort study, conducted in a referral hospital in Tanzania. Patients who underwent burn scar contracture release surgery in 2017-2018 were eligible. ROM (goniometry), disability (WHODAS 2.0) and QoL (EQ-5D) were assessed. The ROM data were compared to the ROM that is required to perform activities of daily living without compensation, i.e. functional ROM. Assessments were performed preoperatively and at 1, 3, 6 and 12 months postoperatively. RESULTS: In total, 44 patients underwent surgery on 115 affected joints. At 12 months, the follow-up rate was 86%. The mean preoperative ROM was 37.3% of functional ROM (SD 31.2). This improved up to 108.7% at 12 months postoperatively (SD 42.0, p < 0.001). Disability-free survival improved from 55% preoperatively to 97% at 12 months (p < 0.001) postoperatively. QoL improved from 0.69 preoperatively, to 0.93 (max 1.0) at 12 months postoperatively (p < 0.001). Patients who regained functional ROM in all affected joints reported significantly less disability (p < 0.001) and higher QoL (p < 0.001) compared to patients without functional ROM. CONCLUSIONS: Contracture release surgery performed in an LMIC significantly improved functional ROM, disability and QoL. Results showed that regaining a functional joint is associated with less disability and higher QoL.

Expression patterns of chondrocyte genes cloned by differential display in tibial dyschondroplasia.

Tibial dyschondroplasia (TD) appears to involve a failure of the growth plate chondrocytes within growing long bones to differentiate fully to the hypertrophic stage, resulting in a mass of prehypertrophic chondrocytes which form the avascular TD lesion. Many biochemical and molecular markers of chondrocyte hypertrophy are absent from the lesion, or show reduced expression, but the cause of the disorder remains to be identified. As differentiation to the hypertrophic state is impaired in TD, we hypothesised that chondrocyte genes that are differentially expressed in the growth plate should show altered expression in TD. Using differential display, four genes, B-cadherin, EF2, HT7 and Ex-FABP were cloned from chondrocytes stimulated to differentiate to the hypertrophic stage in vitro, and their differential expression confirmed in vivo. Using semi-quantitative RT-PCR, the expression patterns of these genes were compared in chondrocytes from normal and TD growth plates. Surprisingly, none of these genes showed the pattern of expression that might be expected in TD lesion chondrocytes, and two of them, B-cadherin and Ex-FABP, were upregulated in the lesion. This indicates that the TD phenotype does not merely reflect the absence of hypertrophic marker genes, but may be influenced by more complex developmental mechanisms/defects than previously thought.

Cloning differentially regulated genes from chondrocytes using agarose gel differential display.

The technique of RNA differential display has been used extensively to clone differentially expressed genes from a wide variety of cells and tissues. Recently, a simplified method of cloning differential display products, separated on agarose gels, was described. Here we report an adaption of this method, using total RNA, to clone differentially expressed genes. The approach is simple and rapid, and requires only small quantities of total RNA. Utilising this approach, we have cloned three differentially regulated genes from chondrocytes stimulated to hypertrophy in vitro, and confirmed their pattern of expression by Northern blotting. These gene fragments were sequenced and found to correspond to known genes, although only one has previously been isolated from chondrocytes.

Passive-active immunization in infants of hepatitis Be antigen-positive mothers. Comparison of the efficacy of early and delayed active immunization.

OBJECTIVE: To assess the efficacy of late active immunization against hepatitis B concomitant with diphtheria, pertussis, tetanus, and polio vaccine in high-risk infants receiving hepatitis B immune globulin at birth. DESIGN: Randomized study of infants born to mothers positive for hepatitis B surface antigen (HBsAg) and hepatitis Be antigen (HBeAg). SETTING: Three large city hospitals and one rural area providing prenatal care and obstetric services. SUBJECTS: Eighty neonates of HBsAg- and HBeAg-positive carrier mothers received 0.5 mL/kg of body weight hepatitis B immune globulin within 2 hours of birth and hepatitis B vaccine (10 micrograms) at 0, 1, 2, and 11 months of age (group A) or at 3, 4, 5, and 11 months of age concomitant with diphtheria, pertussis, tetanus, and polio immunization (group B). A second dose of hepatitis B immune globulin was given to infants on schedule B at 3 months. MAIN OUTCOME MEASURES: Blood samples were collected at 0, 3, 6, 11, and 12 months of age and tested for antibodies against hepatitis B core antigen and HBsAg. Follow-up visits were scheduled annually up to 5 years of age. RESULTS: Eight infants were excluded from analysis. During the study period, six children became HBsAg carriers, three in each group, which corresponds to a 5-year incidence of infection of 9% and 8% for groups A (three of 35) and B (three of 37), respectively. Subclinical infections (persistent anti-HBc positivity beyond month 12 or appearance of anti-HBc) were encountered in another eight infants (four in each group). CONCLUSION: Late active immunization starting at 3 months of age appears to provide similar protective efficacy as active immunization starting at birth when combined with hepatitis B immune globulin at 0 and 3 months of age.

Prevention of hepatitis B infection in newborns through mass screening and delayed vaccination of all infants of mothers with hepatitis B surface antigen.

Beginning in 1982 all pregnant women undergoing prenatal routine blood analysis in three large city hospitals and one large rural area were tested for hepatitis B surface antigen (HBsAg). Infants of all HBsAg-positive mothers received hepatitis B immunoglobulin (HBIg), 0.5 mL/kg of body weight within two hours of birth and, after randomization, 10 micrograms of hepatitis B vaccine either at 0, 1, 2, and 11 months of age (schedule A) or at 3, 4, 5, and 11 months of age (schedule B). A second injection of HBIg (1 mL) was given to infants on schedule B at 3 months of age. Blood samples were obtained at 3, 6, 11, 12, 24, and 36 months. In a two-year period, 28,412 pregnant women were tested for HBsAg; screening efficiency varied between 85% and 98%. The overall prevalence of HBsAg was 0.8%, with a marked variation between urban centers (2.2%) and the rural area (0.3%). Vaccinations were received by 180 of 193 infants of HBsAg-positive mothers (90 on schedule A and 90 on schedule B). Concentrations of hepatitis B surface antibody less than 10 IU/L were observed in nine instances in five children from group A and in seven instances in six children from group B. Four hepatitis B viral infections (two HBsAg carriers, two who underwent antihepatitis B core seroconversions) were recorded in group A v one infection (antihepatitis B core seroconversion) in group B. The protective efficacy of the program (screening plus passive immunization and delayed vaccination) was 94%. The estimated cost of preventing one cae of hepatitis B infection in neonates was $3,000 (US currency).(ABSTRACT TRUNCATED AT 250 WORDS)

Contamination of small-volume medication nebulizers and its association with oropharyngeal colonization.

The effect of the use of small-volume medication nebulizers on oropharyngeal colonization with potentially pathogenic Gram-negative bacilli was investigated in 95 patients with respiratory disease, of whom 54 used nebulizers and 41 were controls. Inhalation therapy had a significant effect on colonization, with a relative risk of more than four. Age over 60 years also showed a significant association with colonization. One-third of the nebulizers sampled were contaminated, 71% with Gram-negative bacilli. A direct route of contamination could be demonstrated in 28% of the patients. Medication nebulizers should be thoroughly cleaned after use and stored dry between patients.

Passive-active immunisation of neonates of HBsAg positive carrier mothers: preliminary observations.

Screening of pregnant women for hepatitis B surface antigen (HBsAg) in three areas of Holland led to the identification of HBsAg carriers, 20 of whom were subsequently delivered. Within two hours after birth all infants received hepatitis B immune globulin (0.5 ml/kg body weight) and, after randomisation, hepatitis B vaccine (10 micrograms) was given either at 0, 1, and 2 months of age or at 3, 4, and 5 months of age, the latter concomitantly with DPTP vaccination. Eighteen infants complying with the protocol were followed up for at least six months. No side effects were observed after either passive or active immunisation. All infants developed high concentrations of anti-HBs antibodies; no interference of high dose passive immunisation with active immunisation was observed. Concentrations of anti-HBs at three months were significantly lower in infants given delayed active immunisation than in those given early active immunisation. These data suggest that passive-active immunisation against hepatitis B virus infection is well tolerated by neonates under 3 months of age and that both early and late active immunisation in combination with passive immunisation will result in excellent anti-HBs production.