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.

The Effect of Inhalation Aromatherapy on Sedation Level, Analgesic Dosage, and Bispectral Index Values during Donor Site Dressing in Patients with Burns: A Randomized Clinical Trial.

OBJECTIVE: To determine the effect of inhalation aromatherapy on sedation level, analgesic dosage, and bispectral index (BIS) values during donor site dressing in patients with burns. METHODS: This trial was conducted on 62 patients with burns requiring donor site dressing who were admitted to the Burn Center of Imam Reza Hospital, Mashhad, Iran. In the intervention group, the patients inhaled damask rose 40% and lavender 10% essential oils during donor site dressing change, whereas in the control group, the site was dressed using routine protocol. Sedatives and analgesics were prescribed until the levels of brain activity achieved light sedation. The brain activity and sedation levels were measured before and after the donor site dressings using the BIS. Data were analyzed using the analysis of covariance and the two-way analysis of variance with repeated measures. RESULTS: All 62 patients completed the study. The required doses of ketamine (P < .001), fentanyl (P = .003), morphine (P < .001), and propofol (P < .001) were significantly lower in the intervention group. The BIS was also significantly lower in the intervention group (P < .001). Heart rate decreased significantly during the aromatherapy, as well as after analgesic and sedative consumption (P < .001). CONCLUSIONS: The inhalation of damask rose and lavender essential oils is an effective intervention to reduce the doses of sedative and analgesic drugs administered as well as BIS during donor site dressing change in patients with burns.

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.

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.