Cohort analysis of 50% lethal area (LA50) and associating factors in burn patients based on quality improvements and health policies.

Burn injuries are among the common traumatic injuries, which can be accompanied with lifelong morbidity and mortality. The Lethal Area Fifty Percent (LA50) index is another reliable outcome measurement tool that assesses the standard of medical care at burn centers. It is widely used as a benchmark for assessing the quality of burn care and is considered the percentage at which 50% of burn patients are expected to die because of burn-related injuries. We aimed to determine and compare the LA50 in burn patients admitted to Shiraz Burn Referral Centers in 2018-2021 and 2011-2018 with regard to improving the quality of special care and infection control in the new hospital. We conducted a retrospective cohort analysis on patients admitted to Amir al-Momenin Burn Injury Hospital in Shiraz, Fars, Southern Iran. Data were retrospectively gathered from March 2011 to January 2022, and subsequently analyzed with standard statistical analysis, and also multivariate and probability analysis. A total of 7382 patients with acute burns injuries were identified. Among them, 4852 (65.7%) patients were men, and the median age was 27 years [Q1-Q3 7-40; range 1-98]. Most of the patients were in the pediatric and early adulthood age range, with 76.2% being younger than 40 years old. The median TBSA was 24% [IQR 14, 43], and the median duration of hospitalization was 11 [IQR 11] days. Most injuries were secondary to flame and fire (33.5%; n = 2472). The mortality rate in our study was 19.0% (n = 1403). We evaluated our patients based on two main time intervals: March 2011 till February 2018 (n = 3409; 46.2%), and March 2018 to January 2022 (n = 3973; 53.8%). Based on multivariate analysis, the second interval of our study was significantly correlated with a more female patients, higher age, lower TBSA, less burn injuries due to scald, contact, but more frequent fire and flame injuries, and also lower mortality rate. Factors correlated with higher mortality included male gender, older age, shorter hospitalization duration, higher TBSA, etiology of fire and flame, and accidental burn injuries. A Baux score of 76.5 had a sensitivity of 81.1%, specificity of 87.3%, accuracy of 86.1% in predicting mortality among our patients. The mortality probability for the study intervals were 20.67% (SD 33.0%) for 2011-2018, and 17.02% (SD 29.9%) for 2018-2022 (P < 0.001). The LA50 was 52.15 ± 2 for all patients. This ammount was 50 ± 2% in 2011-2018, and 54 ± 2 in 2018-2022 (P < 0.001). The mean LA50 values showed significant improvements following significant modifications in our critical care for burn victims, including augmented intensive care unit capacity, prompt relocation of inhalation burn cases to the intensive care unit, establishing a well-trained multidisciplinary team, and improved infection control. To improve outcomes for burn patients in developing countries, major changes should be made in the management of burn patients and LA50 is a reliable assessment tool for evaluating the how these changes affect patient's outcomes.

Epidemiology of burn injuries among adult females in southern Iran; a retrospective study from 2007 to 2022.

Burn -by flame, flush, scald, electrical, and chemical types- accounts for 5-12% of trauma injuries worldwide. In Iranian studies, females were the main victims of domestic burns with higher mortality and frequencies. This retrospective study evaluates the epidemiology and etiology of burn injuries in females aged 25-64 years between October 2007 to May 2022 in southern Iran. Demographics and burn etiology information were collected by questionnaires at admission. Univariate and multivariate regression analysis was used to determine the relationship between variables and burn mortality. Pearson's Chi-Square and One-way ANOVA tests were utilized to compare different burn etiologies. Of 3212 females with burn injuries, 1499 (46.6%) were included with a mean age of 38.5 ± 10.8 years. Flame (59.7%) and flush (28.9%) were significantly the most common injuries mechanism. Burn was most common in rural areas (53.9%) and indoor settings (62.1%) (P-value < 0.001). 77.9% of the population were under-diploma (P-value < 0.001), and 3.5% were divorced with higher burn-suicide attempts. The mean Total Body Surface Area (TBSA%) was 41.1 ± 28.3%, and the mean Length of Stay (LOS) was 14.5 ± 13.2 days with a 39.1% mortality rate. With univariate and multivariate analysis, TBSA%, indoor places, flame, flush, and urban living were risk factors for burn mortality. Briefly, flame in indoor settings is the most common type of burn injury affecting adult females with lower educational levels living in rural areas. Such epidemiological studies of burns in adult females may be helpful for health policymakers to develop burn prevention programs.

Prevalence of Suicide by Self-immolation Among Children in Southern Iran.

Self-immolation is considered among the most rigorous acts of suicide. Lately, this act has increased in children. We evaluated the frequency of self-immolation among children in the largest burn referral center in southern Iran. This cross-sectional study was conducted from January 2014 to the end of 2018 at a tertiary referral burn and plastic surgery healthcare center in southern Iran. Subjects were pediatric self-immolation burn patients registered as outpatients or inpatients. The patients' parents were contacted regarding any incomplete information. Among 913 children admitted due to burn injuries, 14 (1.55%) were admitted with an impression of suicidal self-immolation. Among self-immolation patients, the ages ranged from 11 to 15 years (mean: 13.64 ± 1.33), and the average burnt percentage of total body surface area was 67.07 ± 31.19%. The male-to-female ratio was 1:1, and the majority were from urban areas (57.1%). The most frequent cause of burn injury was fire (92.9%). There was no history of family mental illness or suicide among the patients, and only one of the patients had an underlying disease of intellectual disability. The mortality percentage was 64.3%. The percentage of childhood suicidal attempts by burn injuries was alarmingly high among children aged from 11 to 15. While contrary to many reports, we reported this phenomenon to be relatively similar between genders, and also between urban and rural patients. Compared with accidental burn injuries, the self-immolation group had significantly higher age and burn percentage, and were more frequently caused by fire, occurred outdoors, and resulted in mortality.

Therapeutic Efficacy of Great Plantain (Plantago major L.) in the Treatment of Second-Degree Burn Wounds: A Case-Control Study.

Background: Great plantain (Plantago major L. or P.major) is a medicinal plant that is available all around the world. The whole plant has several bioactive compounds including terpenoids, flavonoids, phenolic compounds, alkaloids, fatty acids, iridoid glycosides, polysaccharides, and vitamins. Scientific studies have recognized several medical benefits like wound healing, anti-inflammatory, antimicrobial, antiulcerative, and antioxidative agents. The wound-healing capacity of this plant has been investigated under in vivo and ex vivo conditions. In the current study, we aim to compare the therapeutic effect of the P.major extract with 1% sulfadiazine on the healing of second-degree burn wounds. Method: Second-degree burn victims were included in our study. The investigation and control group, respectively, received P. major ointment 10% and silver sulfadiazine ointment 1%. The bacterial culture from the wound site was taken on days 3, 7, 10, 13, and last day of hospitalization. Patients' subjective complaints were obtained through the visual analog scale (VAS). All patients were treated and evaluated in the hospital. Result: Among the 15 patients, 11 were male, and the mean age was 33.3 years. The average complete healing duration was 11.73 vs. 13 days in the P. major and control group, respectively (P=0.166). On the third day, infection control was similar between the two groups, and on the seventh day, all bacterial cultures were negative. Although there was a significant reduction in pain scores during the recovery time, no significant differences in pain reduction were noted between the two groups (P=0.849). Conclusion: We showed that P.major ointment is a safe and suitable herbal compound in the treatment of second-degree burn wounds that not only has wound-healing properties but also is an analgesic and antimicrobial compound.

Socioeconomic Features of Burn Injuries in Southern Iran: A Cross-sectional Study.

Burn injuries are among the most traumatic incidences which could be associated with substantial morbidity and mortality. The incidence of these injuries differs based on population socioeconomic characteristics. In this study, we aim to evaluate the distribution of burn injuries based on socioeconomic and causative factors. Relative features from the targeted population were obtained and evaluated. Data were extracted in August 2019 and statistical analysis of the data was conducted from February 2020 to April 2020. This cross-sectional record-based study was conducted from 2008 to 2016 in a main referral center for burn injuries in the southern Iran. Participants included burn survivors and burn patients who were registered as outpatients or inpatients. A total of 4919 burn cases with a mean age of 31.91 ± 17.33, including 2926 (59.5%) males and 1993 (40.5%) females was reported. The majority of our cases had an educational level of under diploma (40.72%). A significant correlation between age, gender, and percentage of burn with the level of education was recorded (P < .001). The most frequent cause of burn injuries was flame with 2537 (51.9%) cases. The most susceptible population to burn injuries were reported to be poorly educated individuals, which emphasizes the preventive role of education.

Effect of dermal fibroblasts and mesenchymal stem cells seeded on an amniotic membrane scaffold in skin regeneration: A case series.

BACKGROUND: Skin wound healing has always been a challenging subject as it involves the coordinated functioning of various cells and molecules. Any disorder in wound healing can cause healing failure and result in chronic wounds. In this study, we hypothesized that co-cultured dermal fibroblasts (DFs) and Wharton's jelly mesenchymal stem cells (WJ-MSCs) seeded on an acellular amniotic membrane scaffold could be used to promote skin regeneration in chronic ulcers. MATERIALS AND METHODS: In this case series, the chronic wounds of five diabetic patients aged between 30 and 60 years were treated with co-cultured WJ-MSCs and DFs seeded on an acellular amniotic membrane. Treatment was applied and the wound healing process was evaluated every three days for nine days, with the patients being subsequently followed up for one month. The wound healing percentage, time taken for the wound to heal, and wound size were monitored. RESULTS: The mean wound healing rate (WHR) increased progressively in all lesions. The mean percentage of wound healing after transplantation of the biological scaffold enriched with WJ-MSCs and autologous DFs after treatment was 93.92%, respectively. The healing percentage significantly increased after three days; significant decreases in wound size and healing time were recorded after six and nine days of treatment, respectively (p < 0.002); and total skin regeneration and re-epithelialization were achieved by the ninth day of treatment. There were no side effects or complications. CONCLUSION: Given the current problems and complications presented by chronic wounds, Novel Clinical approaches involving cell therapy and tissue engineering can be regarded as an attractive therapeutic option for the treatment of chronic and difficult-to-heal wounds.

Suicide by self-immolation in southern Iran: an epidemiological study.

BACKGROUND: Self-immolation, as a method of suicide, is one of the most violent and extreme ways which is usually attempted by the ignition of inflammable materials, with more than 70% fatality rate. In the literature, Iran has been reported to have a high rate of self-immolation; therefore, this study aimed to evaluate the prevalence and epidemiological features of self-immolated patients. METHODS: In this retrospective cross-sectional multicenter study, data from burn patients from 2007 till 2017 due to self-immolation and suicide were enrolled in our study. RESULTS: Based on our data, 657 out of 3530 burn patients (18.6%) with a mean age of 31.15 (SD = 0.452) were documented as suicidal attempts; the majority were female (63.2%) and married (66.3%). Most of the patients were from rural areas (58.3%) with an education level of under diploma (63.2%). Of the patients in our study, 22 (8.7%) had comorbid systemic diseases and 115 (50.5%) had psychiatric disorders. CONCLUSION: Due to the high prevalence of suicide by self-immolation among the Iranian population, further studies to evaluate the risk factors and clarify the high-risk group for more targeted approaches are recommended.

The effect of allogenic human Wharton's jelly stem cells seeded onto acellular dermal matrix in healing of rat burn wounds.

BACKGROUND: Various methods were introduced to overcome the autograft shortage in burn wound care, including cell transplantation and tissue engineering. AIMS: To evaluate the healing effect of allogenic human Wharton's jelly stem cells (hWJSCs) seeded onto acellular dermal matrix (ADM) in rat burn injuries. PATIENTS AND METHODS: Human Wharton's jelly stem cells provided from umbilical cord tissue were characterized before transplantation, and the growth kinetic was determined. Skin samples from cosmetic surgeries were used for preparation of ADM. Forty male Sprague Dawley rats were randomly divided into 4 equal groups. Third-degree burn was induced for all animals by exposing to hot water using a 2 cm ring for 10 seconds. Group 1 was burned rats that did not receive any treatment. After burn injury, the second group received silver sulfadiazine (SSD), the third group was treated just by using ADM, and the fourth group received 2 × 106 hWJSCs seeded onto ADM. The animals were euthanized for histologic evaluation after 7, 14, and 21 days. RESULTS: Human Wharton's jelly stem cells were characterized to be spindle shape and positive for osteogenic and adipogenic induction and for mesenchymal markers but lacked hematopoietic markers. Population doubling time (PDT) was 40.1 hours with an increasing growth trend until day 6th. Macro- and microscopically, the healing was mild in ADM group and moderate in ADM + hWJSCs group after 21 days. CONCLUSION: Allogenic hWJSCs seeded onto ADM improved the healing process in burn wounds denoting to their therapeutic and anti-inflammatory effects in burn wounds that can be added to the literature.

Mortality and Body Mass Index in Burn Patients: Experience from a Tertiary Referral Burn Center in Southern Iran.

BACKGROUND: The role of obesity has been widely studied as a determinant factor of increasing mortality in surgical patients. In this study we aimed to investigate the association of mortality determinants with obesity classification and BMI score in burn patients admitted to a tertiary referral center in Southern Iran. METHODS: In this retrospective cross-sectional study, medical profiles of burn patients admitted from 2016 to 2017 were obtained from Amiralmomenin Burn Hospital, a tertiary referral burn center affiliated to Shiraz University of Medical Sciences, Shiraz, Iran. Demographic, and clinical characteristics as well as patient outcomes were recorded to determine prognostic factors in fatal burns based on anthropometric measurements. RESULTS: Among 101 patients who were enrolled in this study including 73 males and 28 females, mean age was 34.85±12.04 years, total burn surface area (TBSA) was 37.37 (10.50%), BMI was 25.46±5.33 kg/m2 and hospital stay was 22.28±13.62 days. Overall mortality rate was 24.7% with 25 expired cases. Logistic regression demonstrated significant association of older age, male gender, and greater TBSA with mortality. However, difference in mortality rate in patients with BMI of 25 kg/m2 (27.4%) in comparison to patients with BMI<25 kg/m2 (18%) did not reach statistical significance. CONCLUSION: Although patients with higher BMI had increased mortality rate following burn injury, this finding showed no significant association. Further studies with larger samples may be necessary to conclude a causal association between BMI and mortality in burn patients.

Evaluation of Patients' Satisfaction and Functional Outcome of Dorsal Hand Unit Reconstruction in Burn Patients in Shiraz, Southern Iran.

The aim of this study was to assess patients' satisfaction and functional outcome of dorsal hand unit reconstruction in burn patients in Shiraz, southern Iran.From September 2013 to February 2017, 11 patients (15 hands) with hand aesthetic complaint who were unhappy with their hand appearance were included for dorsal hand unit reconstruction. Under general anesthesia and tourniquet control, the burned tissue on dorsal surface of the hands was excised and a thick partial thickness skin graft was used for coverage, whereas the fingers were fixed by sutures to the palm. After 1 year, the five-points scale was used for evaluation of patients' satisfaction regarding the five major activities considered for hand function before and after operation. The mean age of the patients was 25.8 ± 5.17 years. The skin grafts were well taken. Six (40%) and eight patients (53%) reported the result of operation as completely satisfied and satisfied, respectively. Dorsal hand unit reconstruction in patients with dorsal hand contracture and significant dorsal scar was shown to simultaneously improve the function and aesthetic outcome of the surgery.

Self-Burns in Fars Province, Southern Iran.

BACKGROUND: The alarming incidence of self- burning provoked to set up a multidisciplinary preventive program to decrease the incidence and complications of this harmful issue. This study investigated the incidence and the preventive measures in self-burn in Fars Province, southern Iran. METHODS: This study was a longitudinal prospective design on trend of self-inflicted burn injuries in Fars province after setting up a regional multidisciplinary preventive plan (2009-2012). RESULTS: From 18862 admitted patients, 388 (2%) committed self-burning. While the incidence showed a constant decrease in proportion of suicidal cases among all admitted patients (2.5% to 1.6%). The mean age of self-burning victims ranged from 28.3±10.8 to 30.3±11.7 years. The female victims comprised 67.4% of all suicidal burn patients (Female to male ratio: 2.18). The leading causes of suicide commitment were familial conflicts (75.6%) and psychological problems (16.7%). CONCLUSION: It is crucial to continue the regional preventive programs and pave the way to set up national, and even international collaborations to alleviate relevant financial, social, cultural and infrastructural difficulties in order to have lower incidence for this dramatic issue.

Detection of blaPER-1 & blaOxa10 among imipenem resistant isolates of Pseudomonas aeruginosa isolated from burn patients hospitalized in Shiraz Burn Hospital.

BACKGROUND AND OBJECTIVES: Pseudomonas aeruginosa is one of the most important Gram negative opportunistic bacteria which causes infection among burn patients. Resistance to the antibiotics in this group of bacteria is increased due to the activity of extended spectrum ß-lactamase (ESBLs) genes. In the current study, we investigated the prevalence of two genes (blaPER-1 & blaOxa10 ) related ß-lactamase genes among imipenem resistance clinical isolates of P. aeruginosa in hospitalized patients. MATERIALS AND METHODS: From May 2010 to March 2011, 270 P. aeruginosa isolated from hospitalized burned patients' wounds in Shiraz Burn Hospital, were tested for Imipenem resistance by disk diffusion method. Presence of ESBLs exo-enzyme, blaPER-1 and blaOxa10 genes were also evaluated in the resistant isolate. RESULTS: 210 (77.7%) of 270 P. aeruginosa isolates were resistant to imipenem. blaPER-1 and blaOxa10 were detected among 168 (80.0%) of imipenem resistant isolates. Furthermore, 160 (76.2%) of them had blaOxa10 gene and 84 (40.0%) of them had blaPER-1 while 63 (30.0%) resistant isolates contained both genes simultaneously. CONCLUSION: This study showed a high prevalence of blaPER-1 and blaOxa10 genes in hospitalized burn patients in south west of Iran. Therefore, it's highly recommended to perform such tests routinely to evaluate the resistance pattern in order to better antibiotic selection in the burned patients.