Long-term consequences of landmine injury: A survey of civilian survivors in Bosnia-Herzegovina 20 years after the war.

INTRODUCTION: Bosnia-Herzegovina is one of the most landmine-contaminated countries in Europe. Since the beginning of the war in 1992, there have been 7968 recorded landmine victims, with 1665 victims since the end of the war in 1995. While many of these explosions result in death, a high proportion of these injuries result in amputation, leading to a large number of disabled individuals. OBJECTIVE: The purpose of this study is to conduct a survey of civilian landmine victims in Bosnia-Herzegovina in order to assess the effect of landmine injuries on physical, mental, and social well-being. METHODS: Civilian survivors of landmine injuries were contacted while obtaining care through local non-governmental organizations (NGOs) throughout Bosnia-Herzegovina to inquire about their current level of independence, details of their injuries, and access to healthcare and public space. The survey was based upon Physicians for Human Rights handbook, "Measuring Landmine Incidents & Injuries and the Capacity to Provide Care." RESULTS: 42 survivors of landmines completed the survey, with an average follow up period of 22.0 years (±1.7). Of civilians with either upper or lower limb injuries, 83.3% underwent amputations. All respondents had undergone at least one surgery related to their injury: 42.8% had at least three total operations and 23.8% underwent four or more surgeries related to their injury. 26.2% of survivors had been hospitalized four or more times relating to their injury. 57.1% of participants reported they commonly experienced anxiety and 47.6% reported depression within the last year. On average, approximately 3% of household income each year goes towards paying medical bills, even given governmental and non-governmental assistance. Most survivors relied upon others to take care of them: only 41.5% responded they were capable of caring for themselves. 63.4% of respondents reported their injury had limited their ability to gain training, attend school, and go to work. CONCLUSION: The majority of civilian landmine survivors report adverse health effects due to their injuries, including anxiety, depression, multiple surgeries, and hospitalizations. The majority also experience loss of independence, either requiring care of family members for activities of daily living, disability, and inability to be employed. Further research is required to determine effective interventions for landmine survivors worldwide.

Cost Analysis of 48 Burn Patients in a Mass Casualty Explosion Treated at Chang Gung Memorial Hospital.

INTRODUCTION: Little is known about the costs of treating burn patients after a mass casualty event. A devastating Color Dust explosion that injured 499 patients occurred on June 27, 2015 in Taiwan. This study was performed to investigate the economic effects of treating burn patients at a single medical center after an explosion disaster. METHODS: A detailed retrospective analysis on 48 patient expense records at Chang Gung Memorial Hospital after the Color Dust explosion was performed. Data were collected during the acute treatment period between June 27, 2015 and September 30, 2015. The distribution of cost drivers for the entire patient cohort (n=48), patients with a percent total body surface area burn (%TBSA)≥50 (n=20), and those with %TBSA <50 (n=28) were analyzed. RESULTS: The total cost of 48 burn patients over the acute 3-month time period was $2,440,688, with a mean cost per patient of $50,848 ±36,438. Inpatient ward fees (30%), therapeutic treatment fees (22%), and medication fees (11%) were found to be the three highest cost drivers. The 20 patients with a %TBSA ≥50 consumed $1,559,300 (63.8%) of the total expenses, at an average cost of $77,965±34,226 per patient. The 28 patients with a %TBSA <50 consumed $881,387 (36.1%) of care expenses, at an average cost of $31,478±23,518 per patient. CONCLUSIONS: In response to this mass casualty event, inpatient ward fees represented the largest expense. Hospitals can reduce this fee by ensuring wound dressing and skin substitute materials are regionally stocked and accessible. Medication fees may be higher than expected when treating a mass burn cohort. In preparation for a future event, hospitals should anticipate patients with a %TBSA≥50 will contribute the majority of inpatient expenses.

Swiveling a Single Expanded Forehead Flap: A Novel Effective Economical Approach to Total Bilateral Upper and Lower Eyelid Reconstruction.

In our novel approach, a single expanded forehead flap was used to reconstruct bilateral upper and lower eyelids in orbital trauma. A 40-year-old man sustained blast injury resulting in bilateral orbital exenteration and need for bilateral socket and eyelid reconstruction. The sockets were each resurfaced with a temporalis flap. A subgaleal forehead tissue expander was expanded during several weeks until enough tissue was obtained. The single expanded forehead flap was swiveled in stages to reconstruct both upper and lower eyelids beginning with the left eye then the right. With this method, the authors recreated the bilateral upper and lower eyelids with a single pedicled flap and ensured secure retention of prostheses to give an acceptable appearance. The novel approach of swiveling a single expanded pedicled forehead flap to reconstruct bilateral upper and lower eyelids is easy and effective providing adequate like for like autologous tissue, and economical requiring only 1 donor site.

Military trauma care in Birmingham: observational study of care requirements and resource utilisation.

BACKGROUND: The Royal Centre for Defence Medicine is located at University Hospitals Birmingham (UHB). Since 2001 all UK military casualties injured on active duty have been repatriated here for their initial treatment. This service evaluation was performed to quantify the work undertaken, with the aim of providing a snapshot of a year's military trauma work in order to inform the delivery of trauma care in both the military and civilian setting. METHODS: Military patients admitted with traumatic injuries over a 12-month period were identified and the hospital notes and electronic records reviewed. Data were collected focusing on three areas - the details of the injury, information about the in-patient admission, and surgical interventions performed. RESULTS: A total of 388 patients were used in the analysis. Median total length of stay was 10.5 days (IQR: 4-26, range: 0-137 days), and a median 6.0 days (IQR: 3.0-11.0, range: 1-49 days) was spent on intensive care by 125 patients. Surgical intervention was required for 278 (71.6%) patients, with a median of 2.0 operations (IQR: 1.0-4.0, range: 1-27) or 170 min (IQR: 90.0-570.0, range 20-4735 min) operating time per patient. 77% of these patients had their first procedure within 24h of arrival. Improvised explosives accounted for 50.5% of injuries seen. Spearman rank correlation between New Injury Severity Score with length of stay demonstrated significant correlation (p<0.001), with a coefficient of 0.640. A model predicting length of stay based on New Injury Severity Score was devised for patients with battle injuries. CONCLUSION: This report of 12 months work at UHB demonstrates the service commitment to these casualties, describing the burden of care and resource requirements for military trauma patients.

Burden of injury from explosive remnants of conflict in Lao PDR and Cambodia.

In postconflict settings, a substantial number of injuries and related disabilities are caused by land mines and explosive remnants of war. This article reviews the literature on the prevalence of these injuries and subsequent disabilities in Cambodia and Lao PDR. Three major electronic databases were systematically for publications on the prevalence of these injuries. Six studies met the inclusion criteria. Five of these were in Cambodia and 1 in Lao PDR. None of these studies could estimate national prevalence rates of these injuries; only 2 considered the broader impact of related disabilities. The different methodological approaches and limitations of the studies prevented statistical synthesis. The studies reviewed suggested accurate estimates of the prevalence of war injuries and consequent disabilities are missing. There is a need for a comprehensive epidemiological research to quantify the burden that results from such injuries.

Extent, nature and hospital costs of fireworks-related injuries during the Wednesday Eve festival in Iran.

BACKGROUND: Fireworks are commonly used in local and national celebrations. The aim of this study is to explore the extent, nature and hospital costs of injuries related to the Persian Wednesday Eve festival in Iran. METHODS: Data for injuries caused by fireworks during the 2009 Persian Wednesday Eve festival were collected from the national Ministry of Health database. Injuries were divided into nine groups and the average and total hospital costs were estimated for each group. The cost of care for patients with burns was estimated by reviewing a sample of 100 patients randomly selected from a large burn center in Tehran. Other costs were estimated by conducting semi structured interviews with expert managers at two large government hospitals. RESULTS: 1817 people were injured by fireworks during the 2009 Wednesday Eve festival. The most frequently injured sites were the hand (43.3%), eye (24.5%) and face (13.2%), and the most common types of injury were burns (39.9%), contusions/abrasions (24.6%) and lacerations (12.7%). The mean length of hospital stay was 8.15 days for patients with burns, 10.7 days for those with amputations, and 3 days for those with other types of injury. The total hospital cost of injuries was US$ 284 000 and the average cost per injury was US$ 156. The total hospital cost of patients with amputations was US$ 48 598. Most of the costs were related to burns (56.6%) followed by amputations (12.2%). CONCLUSIONS: Injuries related to the Persian Wednesday Eve festival are common and lead to extensive morbidity and medical costs. © 2013 KUMS, All rights reserved.

Higher education does not protect against firework-related injuries: a review of the economic burden and the risk factors of firework-related injuries in the capital of Iran.

OBJECTIVE: To examine the incidence and risk factors of firework-related injuries during the Last Wednesday Eve Festival in Tehran, Iran, with a focus on the association of socio-economic status and educational level with the use of fireworks and the incidence of firework-related injury. STUDY DESIGN: Cross-sectional household survey. METHODS: Using a random cluster sampling approach, a household survey was conducted in Greater Tehran in April 2008. During a structured interview with an adult member of the household, questions were asked about the use of fireworks and any firework-related injuries sustained by household members during the preceding festival. Data were gathered on expenditure on fireworks, medical treatment of firework-related injuries, length of hospital stay for the treatment of these injuries, and damage to personal property by fireworks. RESULTS: The survey included 2456 households in Greater Tehran. At least one member of 18% of these households had used fireworks during the Last Wednesday Eve Festival in 2008. The overall incidence of firework-related injuries was 100 per 100,000 population (95% confidence interval 37-163). The use of fireworks was less common among parents and more common among male children. Individuals who used fireworks were younger than non-users. Younger age and use of fireworks were associated with firework-related injuries (P < 0.05). The mean household expenditure on fireworks was US$1.62. Among the households that had bought fireworks, the mean expenditure was US$9.40 (standard deviation US$16.34). Thirty-two households (1.3%) reported damage to personal property due to fireworks during the festival costing US$3.30-167.20. The regional price of housing in the study area was correlated with the educational level of the head of the household. Higher educational level of the head of the household was associated with participation in firework activities by household members, expenditure on fireworks, and the amount of financial loss due to fireworks (all P < 0.05). CONCLUSION: Fireworks are associated with serious injuries, and impose a non-trivial financial burden on families. While personal use of fireworks was an independent risk factor for firework-related injuries, higher socio-economic status of the household and higher educational level of the head of the household were not protective factors.

[Vacuum-assisted closure of head and neck wounds]. / Vakuumversiegelungstherapie im Kopf-Hals-Bereich.

OBJECTIVE: Since the early 1990s, vacuum-assisted closure (VAC) therapy has been used to treat acute and chronic wounds in almost all disciplines of surgery in Germany. Taking this into consideration, the use of vacuum therapy in the area of head and neck surgery was examined. METHODS: A literature review using MEDLINE (with PubMed) and EMBASE as well as a Cochrane search was performed on 15 December 2010. Search terms included "vacuum therapy", "vacuum-assisted closure", "V.A.C.", "VAC", "(topical) negative pressure (wound therapy)". RESULTS: There were 1,502 peer-reviewed articles about "vacuum therapy" concerning all medical fields in literature. There were a total of 37 publications from the discipline of head and neck surgery (538 patients). Although benefits for the patients are consistently reported, these results are usually presented only in case reports or case series (evidence level IV and V). Positive results are mainly observed for the treatment of lifting defects in reconstructive surgery and for the treatment of acute and chronic soft tissue defects of the neck. Only little experience exists in the vacuum therapy of war wounds in the head and neck region. CONCLUSION: Due to its advantages (i.e., hygienic temporary wound care with support of the continuous decontamination, wound drainage, promotion of granulation tissue formation, and effective wound conditioning), VAC is an integral and indispensable part of modern wound treatment. Analogous to this general experience, a benefit must also be assumed for head and neck wounds. High-quality and reliable studies on the use of VAC must be performed to verify this observation and the future reimbursement of in- and outpatient wound VAC treatment.

Comparison of vacuum-assisted closure to the antibiotic bead pouch for the treatment of blast injury of the extremity.

The surgical care of modern combatants involves treatment of massive extremity wounds from blast mechanism. Currently up to 70% of combat wounds are extremity related. Clinical outcomes for these patients are dependent on the care of these wounds. The Vacuum-Assisted Closure (VAC) Therapy system (KCI Inc, San Antonio, Texas) is ubiquitous in theater and is often considered the only way to treat these wounds. However, the VAC Therapy system is not without problems. It is expensive and requires extensive amounts of product and machinery, as well as functioning suction, and therefore a power source at all times. In addition, the VAC Therapy system requires a trained and vigilant nursing staff. We hypothesized that the antibiotic bead pouch would be a viable alternative to the VAC Therapy system for such blast injuries. We retrospectively analyzed 2 matched groups of 12 patients in terms of outcome and cost. We found that the VAC Therapy system produced more late methicillin-resistant Staphylococcus aureus infections (30%), more unanticipated returns to the operating room for wound problems (4:12 vs 0:12), and required more surgeries overall until closure of the wounds. In addition, the VAC Therapy system cost $12,000 more for 12 patients than the antibiotic bead pouch. We recommend the bead pouch be considered as an equivalent option to the VAC Therapy system in the treatment of blast injury.

The health and economic impact of fireworks-related injuries in Iran: a household survey following the New Year's Festival in Tehran.

INTRODUCTION: Fireworks are used worldwide as a part of national and cultural celebrations. Personal use of fireworks is associated with serious injuries. The "Last Wednesday Eve Festival" is celebrated on the evening before the last wednesday of the Persian calendar year. In recent years, fireworks have been widely used during the festival, which has resulted in injuries. The aim of this study was to determine the incidence and risk factors of fireworks-related injuries associated with the Last Wednesday Eve Festival, in Tehran, Iran. METHODS: A household survey of residents of greater Tehran, using a random cluster sampling design was performed. Number of fireworks-related injuries, expenditures for fireworks and medical treatment of fireworks-related injuries, length of hospital stay for treatment of these injuries and the personal property damage was gathered. RESULTS: Interviews were conducted of 2475 households in greater Tehran. At least one member of 19.8% of these households had used fireworks during the 2007 Last Wednesday Eve Festival. Fireworks-related injuries were more common among households whose members had used homemade fireworks than among households whose members had used only commercially made fireworks (OR=16.5, 95% CI: 5.7-47.5). Forty-five households reported that they had sustained personal property damage caused by fireworks during the festival, costing a mean of US$ 36.60. Households with at least one injured member spent a mean of US$ 441.90 for medical care and a mean of US$ 70.80 for other expenses related to seeking medical care. The overall incidence of fireworks-related injury among household members was 0.2% (95% CI: 0.1-0.3%). Fireworks-related injury incidence was highest in the 10-19 age group. The total estimated number of fireworks-related injuries in Tehran during the 2007 Last Wednesday Eve Festival was approximately 17,000. Among the 20 injured individuals, 4 persons (20.0%) were hospitalised for a mean of 2.8 days. CONCLUSIONS: The personal use of fireworks in Iran is associated with serious injuries and non-trivial economic costs. This study is the first to describe the incidence and economic costs of fireworks-related injuries in a major city in Iran using a population-based survey. To prevent these injuries, individuals should attend public fireworks displays conducted by professionals rather than engage in personal use of fireworks.

Rehabilitation of landmine victims--the ultimate challenge.

Antipersonnel landmines are often used indiscriminately and frequently result in injury or death of non-combatants. In the last 65 years, over 110 million mines have been spread throughout the world into an estimated 70 countries. Landmine victims use a disproportionately high amount of medical resources; the vast majority of incidents occur in regions and countries without a sophisticated medical infrastructure and with limited resources, where rehabilitation is difficult in the best of circumstances. It is suggested that only a quarter of the patients with amputation secondary to landmines receive appropriate care.

The economics of landmine clearance in Afghanistan.

This paper presents an economic evaluation of landmine clearance in Afghanistan. The main benefits comprise increased agricultural output, saved transport time and running costs, saved human casualties and the saved costs of supporting refugees and displaced persons. An investment of US$100 million between 1988 and 1998 is estimated to provide annual benefits of $50.3 million per annum between 1999 and 2008. This translates into net present values of between $935 and $1,744 million, depending on the rate of discount used. This contrasts with the negative NPVs estimated for several other countries.

Major pediatric hand trauma associated with fireworks.

OBJECTIVES: To characterize the injury pattern and economic impact of major pediatric hand trauma secondary to fireworks. DESIGN: Retrospective. SETTING: Pediatric Level I trauma center. INTERVENTION: N/A MAIN OUTCOME MEASUREMENTS: Fractures, amputations, soft tissue defects, length of hospitalization, number and type of procedures performed were obtained from charts, radiographs, and operative reports. Hospital charges were obtained from the billing office. PATIENTS/PARTICIPANTS: Records of patients with a diagnosis of fireworks-related injuries admitted over a period of ten years were reviewed. Twenty-two patients were identified to have sustained twenty-two hand injuries. The group consisted of nineteen boys and three girls, with an average age of 9.3 years (range, 4 to 17 years). RESULTS: There were thirty-one fractures, nineteen amputations, and one dislocation. The nineteen amputations occurred in nine hands. Local skin graft or flap coverage was required in six hands acutely, and delayed soft tissue procedures were performed on four hands. Four hands had digital neurovascular injuries; two required microsurgical repairs at the time of injury, and two were irreparable. Resource use included: average hospital stay of 4.3 days (range, 0 to 20), average number of trips to the operating room, 1.2 (range, 0 to 3), and average hospital charges of $11,582 (range, $1,035 to $39,489). CONCLUSIONS: This study illustrates the severity of pediatric hand injuries associated with fireworks and the significant burden placed on medical resources in treating these injuries. Efforts toward public education and legislative reforms may help to prevent these unnecessary injuries.

Environmental health consequences of land mines.

This article reviews the literature on the environmental effects of anti-personnel land mines globally. Land mines represent an immediate environmental health problem. Between 60 and 70 million land mines are currently in place in over 70 countries. Designed to kill or main humans, including civilians, they injure an estimated 1, 200 persons and kill another 800 every week. Land-mine injuries tend to be serious; an estimated 300,000 persons worldwide have been disabled by them. The problem, politically very controversial, can be resolved only by preventing the further placement of mines, by demining of areas already mined, and by coping with the personal and environmental devastation that they have already caused. Environmental health personnel should be involved in promoting awareness of the problem, in improving services for land-mine victims, and in promoting political efforts to ban further use of land mines.