Solution-oriented research for paediatric burn prevention in Mongolia: An assessment of prevention tools.

Child burn injuries in Mongolia are often caused by electric cooking appliances used on the floor or low table in traditional tent-like dwellings (called a ger) which have no separate kitchen. To prevent these injuries, we developed a context-specific kitchen rack to make electric appliances inaccessible to children, and the rack was provided to 50 families with children aged 0-3 years living in gers for a pilot test. In the present study, we investigated their opinions about the rack after they used it for about 10 months through semi-structured interviews, their willingness-to-pay (WTP) for the rack using a contingent valuation method, and their preference for potential modifications of the rack using best-worst scaling. The estimated median WTP was about USD 40 (which was higher than USD 37 at the baseline when they started to use the rack). The highest priority of modifications of the rack was to enclose the lower section of the rack with doors (which was originally open without doors to reduce the production cost). A few families did not use the rack in winter because they used heating stoves instead of electric appliances for cooking, but we found a unanimous view that the rack reduces burn injuries to children, which may be reflected in their increased WTP for the rack. These findings would guide us to make our burn prevention efforts more relevant to real-life situations and socially acceptable in Mongolia.

Parental acceptance and willingness to pay for a newly designed kitchen rack to reduce paediatric burns.

The majority of pediatric burns in Mongolia occur within the home, particularly in the spaces dedicated to cooking. This makes home environment modification a priority for injury prevention. Many of these injuries are caused by electric appliances used in traditional tent-like dwellings (called a ger). In the present study, we designed and provided a context appropriate kitchen rack to 50 households with children aged 0-3 years living in gers and investigated parental views on the acceptability of the rack and willingness-to-pay (WTP) through face-to-face structured individual and group interviews and the contingent valuation method. We used the DCchoice package of R to estimate the median WTP and its 95% confidence interval by the household income, previous experience of childhood burn injury, and the number of children in the household. There was a total of 89 children aged <5 years in the 50 households, with a total of 59 burn experiences since birth including 29 treated at inpatient facilities. The median WTP was MNT 106,000 (about USD 37). The WTP appeared to be higher for the households with a higher income, more severe child burn experiences, and a greater number of children in the household. In the group interviews conducted after 4-6 weeks of routine use, the participants indicated that the use of the rack had resulted in a less stressful cooking environment, and the kitchen rack was described as a positive contribution to the reduction of risk to their young children. Whilst there were some suggestions for minor modifications, the rack was well accepted as a means of child burn prevention by the parents of infants and toddlers in Mongolia.

A Structured Review to Assess the Current Status of Cost-Based Burns Research in Nepal.

The management of burns is costly and complex. The problem is compounded in low and middle income countries (LMICs) where the incidence of burn injuries is high but infrastructure and funding for management and prevention is limited. Cost of illness studies allows for quantification of the costs associated with public health problems. Without cost quantification, focus and allocation of funding is challenging. The authors explored the availability of cost-focused burns research data in a target LMIC. The focus of their research was Nepal. A structured literature review including published papers, Ministry of Health (MOH) and World Health Organization (WHO) statistics was conducted to identify cost of illness studies or evidence relating to burn-related resource and costs. Gaps in the evidence base were highlighted. Research methodologies from other LMICs were reviewed. We found 32 papers related to burn injury in Nepal, one key MOH document and one relevant WHO data source. Most research focused on the epidemiology and etiology of burns in Nepal. Of the papers, only 14 reported any type of burn-related resource use and only 1 paper directly reported (limited) cost data. No studies attempted an overall quantification of the cost of burns. MOH statistics provided no additional insight into costs. Our study found an almost complete lack of cost-focused burns research in Nepal. Primary research is needed to quantify the cost of burns in Nepal. Initial focus could usefully be on the cost of care in tertiary hospitals. A full cost of burns for Nepal remains some way off.

Burns in Nepal: a participatory, community survey of burn cases and knowledge, attitudes and practices to burn care and prevention in three rural municipalities.

OBJECTIVES: As part of an ongoing, long-term project to co-create burn prevention strategies in Nepal, we collected baseline data to share and discuss with the local community, use as a basis for a co-created prevention strategy and then monitor changes over time. This paper reports on the method and outcomes of the baseline survey and demonstrates how the data are presented back to the community. DESIGN: A community-based survey. SETTING: Community based in three rural municipalities in Nepal. PARTICIPANTS: 1305 households were approached: the head of 1279 households participated, giving a response rate of 98%. In 90.3% of cases, the head of the household was male. RESULTS: We found that 2.7% (CI 1.8 to 3.7) of 1279 households, from three representative municipalities, reported at least one serious burn in the previous 12 months: a serious burn was defined as one requiring medical attention and/or inability to work or do normal activities for 24 hours. While only 4 paediatric and 10 adult cases in the previous 12 months reached hospital care, the impact on the lives of those involved was profound. Only one patient was referred on from primary to secondary/tertiary care; the average length of hospital stay for those presenting directly to secondary/tertiary care was 21 days. A range of first-aid behaviours were used, many of which are appropriate for the local context while a few may be potentially harmful (eg, the use of dung). CONCLUSION: The participatory approach used in this study ensured a high response rate. We have demonstrated that infographics can link the pathway for each of the cases observed from initial incident to final location of care.

Quality-of-life evaluation in chronic wounds: comparative analysis of three disease-specific questionnaires.

The study directly compared the feasibility and performance of three instruments measuring health-related quality of life (HRQoL) in chronic ulcers: the Freiburg Life Quality Assessment for wounds (FLQA-w), the Cardiff Wound Impact Schedule (CWIS) and the Würzburg Wound Score (WWS). The questionnaires were evaluated in a randomly assigned order in a longitudinal observational study of leg ulcer patients. Psychometric properties (internal consistency, responsiveness and construct validity) were analysed. Patient acceptance was recorded. Analysis of n = 154 patients revealed good internal consistency (Cronbach's alpha ≥ 0·85) for all instruments. There were minor floor effects in all questionnaires (<1%) and some ceiling effects in the CWIS. Construct validity was satisfactory, for example, correlation with EuroQoL-5D was r = 0·70 in the FLQA-w, r = 0·47/0·67/0·68 in the CWIS dimensions and r = 0·60 in the WWS. The proportion of missing values was higher in the CWIS, and overall patient acceptance was highest in the FLQA-w for wounds (54% best preferences) and lowest in the WWS (14%). In conclusion, the FLQA-w, the CWIS and the WWS are reliable, sensitive and valid instruments for the assessment of HRQoL in leg ulcers. However, they show differences in clinical feasibility and patient acceptance.

Reporting standards of studies and papers on the prevention and management of foot ulcers in diabetes: required details and markers of good quality.

The evidence base for many aspects of the management of foot ulcers in people with diabetes is weak, and good-quality research, especially relating to studies of direct relevance to routine clinical care, is needed. In this paper, we summarise the core details required in the planning and reporting of intervention studies in the prevention and management of diabetic foot ulcers, including studies that focus on off-loading, stimulation of wound healing, peripheral artery disease, and infection. We highlight aspects of trial design, conduct, and reporting that should be taken into account to minimise bias and improve quality. We also provide a 21-point checklist for researchers and for readers who assess the quality of published work.

Contrasting host immuno-inflammatory responses to bacterial challenge within venous and diabetic ulcers.

Within chronic wounds, the relationship between the clinical diagnosis of infection and bacterial/immuno-inflammatory responses is imprecise. This study prospectively examined the interrelationship between clinical, microbiological, and proinflammatory biomarker levels between chronic venous leg ulcers (CVLUs) and diabetic foot ulcers (DFUs). Wound swabs and fluids were collected from CVLUs (n = 18) and DFUs (n = 15) and diagnosed clinically as noninfected or infected; and qualitative/quantitative microbiology was performed. CVLU and DFU fluids were also analyzed for cytokine, growth factor, receptor, proteinase/proteinase inhibitor; and oxidative stress biomarker (protein carbonyl, malondialdehyde, and antioxidant capacity) levels. While no correlations existed between clinical diagnosis, microbiology, or biomarker profiles, increasing bacterial bioburden (≥10(7) colony-forming unit/mL) was associated with significant alterations in cytokine, growth factor, and receptor levels. These responses contrasted between ulcer type, with elevated and decreased cytokine, growth factor, and receptor levels in CVLUs and DFUs with increasing bioburden, respectively. Despite proteinase biomarkers exhibiting few differences between CVLUs and DFUs, significant elevations in antioxidant capacities correlated with increased bioburden in CVLU fluids, but not in DFUs. Furthermore, oxidative stress biomarker levels were significantly elevated in all DFU fluids compared with CVLUs. This study provides further insight into the contrasting disease-specific host responses to bacterial challenge within infected CVLUs and DFUs.

Comparative responsiveness of the Michigan Hand Outcomes Questionnaire and the Carpal Tunnel Questionnaire after carpal tunnel release.

PURPOSE: The literature supports self-administered questionnaire assessment tools for the measurement of outcome after surgical treatment of carpal tunnel syndrome (CTS). Traditional physical measures are less sensitive to clinical changes following carpal tunnel release (CTR) than fully validated designed outcome questionnaires. A number of validated outcome instruments have been compared to determine which is optimal with regard to sensitivity and responsiveness following surgery. To our knowledge, the Michigan Hand Outcomes Questionnaire (MHQ) and the Carpal Tunnel Questionnaire (CTQ) have not been compared in regard to their responsiveness and sensitivity to change following CTR. The aim of this prospective study was to compare the responsiveness of these 2 instruments when evaluating outcomes after CTR. METHODS: Seventy-eight patients diagnosed with CTS and scheduled for unilateral open CTR were recruited and informed consent was obtained after ethics approval. Inclusion criteria were primary procedure, history, clinical signs, and conduction studies consistent with CTS. The MHQ and CTQ were both completed by each patient preoperatively and 6 months postoperatively. RESULTS: Results for all domains of the MHQ and all domains of the CTQ showed significant postoperative improvement. The overall responsiveness of both MHQ and CTQ were large (standardized response mean >or=0.8), however the CTQ demonstrated increased sensitivity to change after CTR compared to the MHQ. Although the standardized response mean (SRM) of the MHQ was 0.8, the SRM of the CTQ was 1.22. Both domains of the CTQ had an SRM well above 0.8, whereas half of the MHQ domains had an SRM below 0.8. CONCLUSIONS: The CTQ has demonstrated a greater responsiveness to clinical change following CTR than the MHQ. Therefore, the CTQ is a more sensitive instrument and researchers in the field of CTS should bear these findings in mind when choosing an outcome instrument for future studies. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic I.

Dressing-related pain in patients with chronic wounds: an international patient perspective.

This cross-sectional international survey assessed patients' perceptions of their wound pain. A total of 2018 patients (57% female) from 15 different countries with a mean age of 68.6 years (SD = 15.4) participated. The wounds were categorised into ten different types with a mean wound duration of 19.6 months (SD = 51.8). For 2018 patients, 3361 dressings/compression systems were being used, with antimicrobials being reported most frequently (n= 605). Frequency of wound-related pain was reported as 32.2%, 'never' or 'rarely', 31.1%, 'quite often' and 36.6%, 'most' or 'all of the time', with venous and arterial ulcers associated with more frequent pain (P= 0.002). All patients reported that 'the wound itself' was the most painful location (n= 1840). When asked if they experienced dressing-related pain, 286 (14.7%) replied 'most of the time' and 334 (17.2%) reported pain 'all of the time'; venous, mixed and arterial ulcers were associated with more frequent pain at dressing change (P < 0.001). Eight hundred and twelve (40.2%) patients reported that it took <1 hour for the pain to subside after a dressing change, for 449 (22.2%) it took 1-2 hours, for 192 (9.5%) it took 3-5 hours and for 154 (7.6%) patients it took more than 5 hours. Pain intensity was measured using a visual analogue scale (VAS) (0-100) giving a mean score of 44.5 (SD = 30.5, n= 1981). Of the 1141 who reported that they generally took pain relief, 21% indicated that they did not feel it was effective. Patients were asked to rate six symptoms associated with living with a chronic wound; 'pain' was given the highest mean score of 3.1 (n= 1898). In terms of different types of daily activities, 'overdoing things' was associated with the highest mean score (mean = 2.6, n= 1916). During the stages of the dressing change procedure; 'touching/handling the wound' was given the highest mean score of 2.9, followed by cleansing and dressing removal (n= 1944). One thousand four hundred and eighty-five (80.15%) patients responded that they liked to be actively involved in their dressing changes, 1141 (58.15%) responded that they were concerned about the long-term side-effects of medication, 790 (40.3%) of patient indicated that the pain at dressing change was the worst part of living with a wound. This study adds substantially to our knowledge of how patients experience wound pain and gives us the opportunity to explore cultural differences in more detail.

Fibroblast dysfunction is a key factor in the non-healing of chronic venous leg ulcers.

Chronic age-related degenerative disorders, including the formation of chronic leg wounds, may occur due to aging of the stromal tissues and ensuing dysfunctional cellular responses. This study investigated the impact of environmental-driven cellular aging on wound healing by conducting a comprehensive analysis of chronic wound fibroblast (CWF) behavior in comparison with patient-matched healthy skin normal fibroblasts (NF). The dysfunctional wound healing abilities of CWF correlated with a significantly reduced proliferative life span and early onset of senescence compared with NF. However, pair-wise comparisons of telomere dynamics between NF and CWF indicated that the induction of senescence in CWF was telomere-independent. Microarray and functional analysis suggested that CWFs have a decreased ability to withstand oxidative stress, which may explain why these cells prematurely senescence. Microarray analysis revealed lower expression levels of several CXC chemokine genes (CXCL-1, -2, -3, -5, -6, -12) in CWF compared with NF (confirmed by ELISA). Functionally, this was related to impaired neutrophil chemotaxis in response to CWF-conditioned medium. Although the persistence of non-healing wounds is, in part, due to prolonged chronic inflammation and bacterial infection, our investigations show that premature fibroblast aging and an inability to correctly express a stromal address code are also implicated in the disease chronicity.

Antibiotic prescribing for chronic skin wounds in primary care.

The aim of this study was to describe and quantify systemic antibiotic prescribing for patients with chronic skin wounds presenting at the primary care, nonspecialist setting. Data for 1 year were extracted from a general practice morbidity database comprising approximately 185,000 patients attending family medical practitioners in Wales. Patients with chronic wounds (PCW) were identified using Read Codes and compared with nonwound patients who were randomly selected after matching for age-band, sex, and general practice. PCW received a significantly greater number of antibiotic courses than nonwound patients (p<0.001). This increased level of prescribing was evident for flucloxacillin, co-amoxiclav, cefaclor, cefalexin, erythromycin, trimethoprim, metronidazole, and ciprofloxacin (p<0.01 for all). While PCW also had a significantly higher prevalence of diabetes (16.5% compared with 6.6%, p<0.001), and attended at general practice significantly more frequently than nonwound patients (median (interquartile range) of 25 (17-40) visits per year compared with 12 (4-20), p<0.001), importantly, exclusion of diabetic patients and analysis of the proportion of visits on which patients received antibiotics did not affect the significance of the difference in antibiotic consumption. These data show a strong association between occurrence of chronic wounds and prescribing of antibiotics in primary health care, and wide variation in the type and duration of antibiotic therapy for chronic wounds. Further work is now indicated to rationalize this prescribing and determine the role that this exposure to antibiotics plays in the prevalence of antibiotic resistance in this at-risk elderly population.

Imiquimod 5% cream monotherapy for cutaneous squamous cell carcinoma in situ (Bowen's disease): a randomized, double-blind, placebo-controlled trial.

BACKGROUND: We conducted a double-blind, placebo-controlled, randomized trial to evaluate the preliminary efficacy and safety of imiquimod 5% cream treatment for cutaneous squamous cell carcinoma (SCC) in situ. METHODS: In all, 31 patients with biopsy-proven cutaneous SCC in situ were randomly assigned to placebo (vehicle) (n = 16) or imiquimod 5% cream (n = 15) daily for 16 weeks. Patients were assessed at week 28 for the primary end point, resolution of cutaneous SCC in situ. RESULTS: Of the 31 patients enrolled, 3 dropped out. Intention-to-treat analysis revealed 11 of the 15 patients (73%) in the imiquimod group achieved resolution of cutaneous SCC in situ, with no relapse during the 9-month follow-up period; none in the placebo group achieved resolution (P < .001). Imiquimod 5% cream was generally well tolerated and there were no serious adverse events. LIMITATIONS: Topical imiquimod 5% cream has proven to be an effective treatment for cutaneous SCC in situ. However, studies to define the ideal dosing regimen and cost-effectiveness are required before it can be accepted as a recognized therapy. CONCLUSIONS: In this controlled trial, patients with cutaneous SCC in situ receiving topical imiquimod 5% cream as monotherapy experienced a high degree of clinical benefit compared with placebo.

Negative-pressure wound therapy: a snapshot of the evidence.

Topical negative pressure (TNP) is a mode of therapy used to encourage wound healing. It can be used as a primary treatment for chronic/complex wounds or as an adjunct to surgery. Based on the evidence to date, the clinical effectiveness of negative-pressure therapy is still unclear. Although case reports and retrospective studies have demonstrated enhanced wound healing in acute/traumatic wounds, chronic wounds, infected wounds, wounds secondary to diabetes mellitus, sternal wounds and lower limb wounds, there are very few randomised controlled trials, with unclear results. The evidence is lacking for the use of TNP therapy for other indications to enhance wound healing such as patients with decubitus ulcers, diabetes and peripheral vascular disease and to improve skin graft take. There have been, as yet, no quality-of-life studies available for negative-pressure therapy. Despite this, the usage of TNP has increased. This review provides an overview of clinical studies using TNP and proposes avenues for further research to elucidate the exact mechanism of TNP, in addition to large randomised controlled clinical trials of patients undergoing this therapy.

Early diagnosis is vital in the management of squamous cell carcinomas associated with chronic non healing ulcers: a case series and review of the literature.

The association between chronic ulcers and squamous cell carcinomas (SCCs) is well established. Their clinical presentations, however, are varied, ranging from innocously appearing lesions to overtly exophytic growths. We present a series of cases with heterogeneous clinical presentations and different treatment outcomes. Case series - patient 1 was a 69-year-old man with an 18-month history of static non healing venous leg ulcer, but no sinister features, biopsy was performed to rule out Marjolin's transformation, histology revealed SCC and treatment was simple excision and skin grafting; patient 2 was a 73-year-old lady with an 18-month history of non healing ulcer (innocuous appearance) over distal interphalangeal joint of index finger, histology revealed SCC with deeper extension and treatment was amputation of distal half of finger; patient 3 was a 73-year-old lady with a 12-month history of non healing fungating leg ulcer with irregular borders and everted edges, histology revealed SCC (tumour eroding tibia and distant metastasis) and treatment was above-knee amputation, radiotherapy and palliation. Whilst SCC is amenable to simple excision in the early stages, delay in diagnosis could result in loss of the affected digit or limb; an SCC which has metastasised is also life threatening. Therefore, a low threshold to biopsy static non healing ulcers or ulcers in unusual sites should be adopted even in those not manifesting any evidence of malignancy.